ArticlePDF Available

Organizational and Command Aspects for Coordinating the Public Health Response to an Outbreak of Acute Renal Failure, Republic of Panama, 2006

Authors:
  • Centers for Disease Control and Prevention/Agency for Toxic Susbtances and Disease Registry
  • DisasterDoc LLC

Abstract and Figures

The Ministry of Health of Panama (MINSA) received several reports of ill persons who had clinical presentations of acute renal insufficiency or failure during September and October 2006. On 01 October 2006, the MINSA formally asked the Pan-American Health Organization (PAHO) and the US Centers for Disease Control and Prevention (CDC) to assist with the investigation. Additional agencies involved in the response included the US Food and Drug Administration (FDA), the Gorgas Institute for Health Studies (GIHS), and the Social Security Health System (SSHS) of Panama. Through a joint effort, the MINSA, CDC, FDA, GIHS, SSHS, and PAHO were able to characterize the illness, identify the etiological agent, identify the population-at-risk, and launch an unprecedented media and social mobilization effort to prevent additional cases. International outbreak responses may require familiarity with basic emergency management principles beyond technical or scientific considerations. The management, logistical capabilities, team interaction, and efficiency of outbreak investigations can be enhanced substantially by having staff already familiar with common operational frameworks for incident responses. This report describes the inter-agency coordination and organizational structure implemented during an international response to identify the cause of an outbreak of acute renal failure in Panama.
Content may be subject to copyright.
CASE STUDY
June 2011 Prehospital and Disaster Medicine
Organizational and Command Aspects for
Coordinating the Public Health Response to
an Outbreak of Acute Renal Failure, Republic
of Panama, 2006
Miguel A. Cruz, MPH;1 Mark E. Keim, MD;1 Joshua G. Schier, MD;1 Raul Gonzalez, MD;2
Angel Valencia, MD;3 Jana L. Telfer, MA1
1. National Center for Environmental
Health/Agency for Toxic Substances and
Disease Registr y, Centers for Disease
Control and Prevention, Atlanta,
Georgia USA
2. Sistema Institucional de Salud para
Emergencias y Desastres, Ministerio de
Salud de Panama
3. Pan American Health Organization,
Panama
Correspondence:
Miguel Cruz, MPH
US Centers for Disease Control and
Prevention
National Center for Environmental
Health/Agency for Toxic Substances and
Disease Registry
4770 Buford Highway, F-09
Atlanta, Georgia 30341 USA
E-mail: mcruz@cdc.gov
Keywords: acute renal failure; command;
coordination; Panama; public health
Abbreviations:
CDC = [US] Centers for Disease Control
and Prevention
DEG = diethylene glycol
EOC = emergency operations center
FDA = [US] Food and Drug
Administration
GIHS = Gorgas Institute for Health
Studies
HC = Health Cluster
IC = incident commander
ICS = incident command system
JIC = joint information center
JOC = joint operation center
MINSA = Ministry of Health Panama
PAHO = Pan-American Health
Organization
UC = unif ied command
Abstract
The Ministry of Health of Panama (MINSA) received several reports of ill persons who
had clinical presentations of acute renal insufficiency or failure during September and
October 2006. On 01 October 2006, the MINSA formally asked the Pan-American
Health Organization (PAHO) and the US Centers for Disease Control and Prevention
(CDC) to assist with the investigation. Additional agencies involved in the response
included the US Food and Drug Administration (FDA), the Gorgas Institute for Health
Studies (GIHS), and the Social Security Health System (SSHS) of Panama. Through a
joint effort, the MINSA, CDC, FDA, GIHS, SSHS, and PAHO were able to character-
ize the illness, identify the etiological agent, identify the population-at-risk, and launch an
unprecedented media and social mobilization effort to prevent additional cases.
International outbreak responses may require familiarity with basic emergency manage-
ment principles beyond technical or scientific considerations. The management, logistical
capabilities, team interaction, and efficiency of outbreak investigations can be enhanced
substantially by having staff already familiar with common operational frameworks for
incident responses. This report descr ibes the inter-agency coordination and organizationa l
structure implemented during an international response to identify the cause of an out-
break of acute renal failure in Panama.
Cruz MA, Keim ME, Schier JG, Gonzalez R, Valencia A, Telfer JL: Organizational
and command aspects for coordinating the public health response to an outbreak of acute
renal failure, Republic of Panama, 2006. Prehosp Disaster Med 2011;26(3):217–223.
Introduction
During the months of September and October 2006, the Ministry of Health of Panama
(MINSA) received several reports of ill persons who had clinical presentations of acute
renal insufficiency or failure. On 01 October 2006, the MINSA and the Gorgas Institute
for Health Studies (GIHS) formally asked the Pan-American Health Organization
(PAHO), the US Centers for Disease Control and Prevention (CDC), and the US Food
and Drug Administration (FDA) to assist with the investigation. Through a joint effort,
the MINSA, GIHS, CDC, FDA, and PAHO were able to characterize the illness,
identify an etiological agent, identify the population at risk, and launch an unprece-
dented media and social mobilization effort.
Domestic outbreak investigations can be complex, and may require a considerable
amount of logistical, technical, and human resources. International setting responses in
addition to these issues may require familiarity with a host country emergency response
and incident command structures. This report describes the operational framework
SARS = severe acute respiratory syndrome Received: 05 August 2010
SISED = Institutional Health System for Emergencies Online publication: 20 September 2011
and Disasters doi:10.1017/S1049023X11006340
SSHS = Social Security Health System
218 Coordinating Public Health Response
Prehospital and Disaster Medicine Vol. 26, No. 3
and inter-agency coordination aspects of an intensive outbreak
investigation to identify the cause of an outbreak of acute renal
syndrome in Panama in 2006.
Background
The leadership in a given jurisdiction ultimately is responsible
for ensuring that necessary and appropriate actions are taken to
protect people and property from the consequences of emergen-
cies and disasters.1,2 Depending on the scope of the event, this
leadership may be at the local, state, regional, or national level.
A key element of preparedness is the development of an inci-
dent management system, such as the incident command system
(ICS), that can effectively coordinate the jurisdiction’s emergency
response actions during an event. An ICS is a flexible framework
for organizing emergency responses, and, in the past several years,
it increasingly has been applied to events related to public health
emergencies and healthcare facilities.3,4 Although its application
or utility as an organizational framework for domestic and inter-
national public health responses has not been fully explored or
documented, the ICS is one of the core disciplines and compe-
tencies suggested for medical and public health professionals.3–7
Public health officials are relatively new to the ICS concept,
and most have limited knowledge and experience in this area.
As such, there is a need for public health ICS models that can
assist members of national and international response agen-
cies to effectively coordinate with each other during emergency
responses. Modern concepts of emergency management systems
describe the need for effective use of ICS, which is based upon
the principles of unity of command, adequate span of control,
chain of command, flexibility, and scalability.8 Within the ICS,
a unified command (UC) is one way to effectively manage emer-
gencies in which multiple responding agencies or organizations,
often times with overlapping jurisdictions, share responsibility
for incident management. A UC may be needed for incidents
involving: (1) multiple jurisdictions; (2) a single jurisdiction with
multiple agencies sharing responsibility; and (3) multiple juris-
dictions with multi-agency involvement.
In ICS, the UC is a system that brings together the incident
commanders of all major organizations involved in an incident
to coordinate an effective response while, at the same time, car-
rying out their own jurisdictional responsibilities. The ICS is
used widely in many countries, including the US. Other than
the United Nations (UN) Health Cluster (HC) system, models
for development of a single, multinational, unified command
structure for responses among sovereign governments, inter-
national organizations, and national institutions are much less
commonly reported.9
In September 2006, the Epidemiology Department in the
Ministry of Health of the Republic of Panama (MINSA) began
receiving reports of ill persons who had a clinical presentation
including acute renal insufficiency, neurological symptoms, and
respiratory failure, which in some cases resulted in death. The
syndrome was named paralysis and acute renal insufficiency syn-
drome (PIR A). The initial investigation of the event involved
epidemiologists from the MINSA, the Gorgas Institute for
Health Studies (GIHS), and the Social Security Health System
(SSHS). On 02 October 2006, MINSA formally requested
assistance from the US Centers for Disease Control and
Prevention (CDC). Scientists from PAHO, the FDA, and the
previously mentioned organizations formed a joint international,
multi-disciplinary investigation team. This team consisted of
epidemiologists, laboratorians, physicians, toxicologists, envi-
ronmental health specialists, and media personnel. The team
ultimately determined that the cause of the outbreak was dieth-
ylene glycol (DEG) contaminated cough syrup that was pro-
duced in-country. As of April 2007, 119 documented cases of
PIRA had been reported to the MINSA. However, thousands
of Panamanians likely were exposed to this product.10
During disease outbreaks such as this, the affected country
may request support from international partners in the form of
technical assistance or personnel to augment local resources.
Upon arrival, international teams may face unnecessary opera-
tional delays due to unfamiliarity with the host country’s emer-
gency response system, and their command and organizational
structures. During the Panama outbreak investigation, an ICS-
like management structure was introduced and adopted by an
international outbreak investigation team. The ICS is a modu-
lar framework that calls for establishing key or staff positions or
functions. These positions, including an incident commander
(IC), agency liaison, public information, and safety officers;
general functional areas, including finance/administration,
logistics, operations, and planning, are established (Figure
1). All organizations worked together efficiently under a UC
with the Panama Minister of Health as the overall Incident
Commander, to identify the cause of the outbreak, which ulti-
mately was determined to be DEG contaminated medication.
This report summarizes the experience in the use of UC dur-
ing an outbreak response in an international setting, describes
challenges, and the potential benefits of using a UC structure
during international outbreak responses.
Methods
In preparation for this report, official correspondence, medi-
cal reports, news stories, situation reports, and after-action
reports from this incident were reviewed. A literature search was
conducted using the key terms public health incident command,
emergency operations centers, and outbreak management. Articles
selected were reviewed for relevant content. Country health
reports, country-specific health statistics, organizational struc-
ture diagrams (organograms), and geographical information
prepared by using data available from public and Panamanian
health authority domains also were reviewed.
Result
Medical System Overview
The Republic of Panama is located in Central America. It bor-
ders Colombia on the east and Costa Rica on the west. Panama’s
population at the time of the outbreak was estimated at
3,339,781.11 Panamas healthcare system is divided into three
groups: (1) MINSA; (2) SSHS: and (3) private healthcare pro-
viders. The MINSA exercises a national regulatory function and
provides primary care and public health-related services.12,13 The
SSHS is a semi-public healthcare system that, through various
plans, provides a variety of health services to members, private
companies, the public sector, contractors, and retirees. Private
healthcare services are available widely for those people who can
afford that level of care.
The MINSA is the agency primarily responsible for carrying
out public health activities in Panama. The MINSA performs
surveillance activities by using a passive disease surveillance sys-
tem. Panama also is home to the GIHS, an institution created
in 1921 that has contributed significantly to developing tropical
Cruz, Keim, Schier, et al 219
June 2011 Prehospital and Disaster Medicine
medicine and laboratory services throughout Central America.
The GIHS also has supported public health responses to large
community and regional disease outbreaks.14–16 Other resources
available in the country include the MINSA bacterial reference
laboratory, the University of Panama chemistry laboratory, and
a US Department of Agriculture animal disease laboratory. The
PAHO Country Office located in Panama is another resource
available for assisting MINSA with public health emergencies
and disasters.17
Emergency Management System Structure for this Event
The Institutional Health System for Emergencies and
Disasters (SISED) is responsible for coordinating emergency
response functions within the MINSA. As with other pub-
lic health emergency operations centers (EOCs), the SISED’s
EOC is staffed around the clock. It serves as the focal point for
Panama’s public health and medical emergencies, maintain-
ing situational awareness and exercising medical control and
coordination.18 During a disaster, SISED coordinates with the
National Civil Protection System (SINAPROC), the emer-
gency management agency of Panama.19 The SISED person-
nel are trained in using the ICS. During this event in Panama,
the MINSA established and directed the UC. Liaison officers
from various public health agencies complemented the UC
structure for the incident.
The CDC team deployed to this investigation ultimately was
augmented by a team from the FDA, which added expertise in
tracing the origin of contamination in such incidents (commonly
referred as a “trace-back” investigation), and pharmacological
man ufa ct u ri ng p ro ce ss e s. Th e PA HO Pa na m a O ff i ce an d PA HO
Emergency Operations Center located in Washington, DC pro-
vided additional epidemiological and logistical support personnel.
Due to the large number of international organizations involved
and influx of much-needed public health personnel, an ICS-like
structure for organizing the incident response was adopted by the
outbreak investigation team. Upon arrival, new personnel were
integrated into already established sections or teams. Additional
support to the f ield teams was provided by the CDC, FDA, and
PAHO EOCs all located in Atlanta, Georgia and Washington,
DC. The CDC arranged transport of diagnostic equipment and
coordinated the rapid delivery of biological samples to specialized
laboratories back in the US using dedicated aircraft.
Establishment of a Joint Operations Center
The staff of the UC discussed the need for identification of a
central point for coordination of the expanding operation and
determined that the space allocated to SISED for emergency
operations was inadequate. A large classroom adjacent to
SISED’s situational awareness room was retrofitted to meet this
need, and became the EOC for the event. To reflect the unified
Cruz © 2011 Prehospi tal and Disas ter Medici ne
Figure 1Traditional Incident Command System Template*
* Introduction to Incident Command System (ICS 100). Available at http://www.fema.gov.
220 Coordinating Public Health Response
Prehospital and Disaster Medicine Vol. 26, No. 3
Cruz © 2011 Prehospi tal and Disas ter Medici ne
Figure 2—Unif ied command structure and team organization established after an outbreak of acute renal failure, Republic of Panama, 2006
MOH = Ministry of Health; IC = Incident Commander; PIO = Public Information Officer; JIC = Joint Information Center; MINSA = Ministerio de Salud;
LNO = Liaison Officer; PAHO = Pan American Health Organization; GIHS = Gorgas Institute of Health Studies; SSHS = Social Security Health System; SISED =
Sistema Institucional de Salud para Emergencias y Desastres; CDC = US Centers for Disease Control and Prevention; FDA = US Food and Drug Administration;
GIS = geographical information systems
Cruz, Keim, Schier, et al 221
June 2011 Prehospital and Disaster Medicine
nature of the international responses, the site was named the
joint operations center (JOC). By 03 October 2006, the facility
had transformed from an empty room to a fully equipped opera-
tions center, complete with Internet and television access, pro-
jectors, status boards, and maps.
The MINSA staffed the JOC with administrative and logis-
tics support staff. This staff coordinated all lodging, transpor-
tation, shipping, purchasing, and customs clearance of medical
equipment and supplies. A motor pool was established to facili-
tate transport of the teams and deliver medical materials and
sampling equipment and supplies. Access to the JOC area was
restricted and monitored by security personnel.
The MINSA’s information technology (IT) office installed
an Internet system and configured access to existing databases.
Information security and confidentiality of personal and medical
information were a primary concern for all agencies, and access
to databases containing patient information was restricted on a
need-to-know basis.
Incident Command Structure
Following principles of ICS, UC leadership remained under
local control, with Panamas Minister of Health serving as the
overall incident commander. The organization of the public
health structure is in Figure 2. The command staff included liai-
sons that were senior representatives or directors of the various
organizations involved (i.e., MINSA, GIHS, SSHS, PAHO,
CDC, and FDA). In addition, a joint information center ( JIC)
was established and staffed by the MINSA, CDC, and PAHO.
The JIC assumed the role of the public information officer. The
MINSA/SISED officials assumed the safety officer role, which
included providing physical security and protection of both
facilities and field teams.
Planning
General staff from MINSA supported other functional areas
of the ICS, such as finance, logistics, operations, and planning.
Planning was a unified command function, and, for that pur-
pose, daily team meetings involving the principal agency liai-
sons from MINSA, GIHS, SSHS, PAHO, CDC, and FDA
were conducted in the JOC. The JOC also provided a setting for
interaction between the various teams.
Operations
The operations section (MINSA, CDC, and PAHO) orga-
nized and coordinated activities to support the field teams, and
to maintain common situational awareness among the agencies
involved. It also was the conduit for coordinating needs with
the JOC. Team structure was organized according to the need
for a sustained outbreak investigation and included surveillance,
case-control study, laboratory, public communication, and clini-
cal teams as described below
Surveillance Team—This team included epidemiologists from
the MINSA, CDC, and PAHO who developed a case defini-
tion for the illness and protocols for reporting cases. They also
maintained a daily case count. Teams visited patients’ homes
looking for clues, obtaining information from relatives, and
observing living conditions and nearby hazards that may have
placed people at risk. In addition, investigators collected samples
of prescribed and over-the-counter medications and remedies
from the patients’ homes.
Case-Control Study TeamThis was a joint team composed of
epidemiologists from the MINSA, GIHS, CDC, and PAHO.
This team was responsible for conducting a case-control study,
including protecting the data and conducting data processing.
The team used specifically trained medical students as inter-
viewers for the case-control study.
Laboratory Team—This joint team, composed of staff from
PAHO and the CDC, was responsible for collecting human
specimens, including postmortem samples. It was responsible for
collecting, labeling, documenting, and processing approximately
1,000 biological samples and raw materials, and rapidly shipping
them to CDC and FDA laboratories in the US. In addition, the
laboratory team was responsible for: (1) purchasing laboratory
materials, shipping containers, and dry ice; (2) arranging courier
services; and (3) working with customs clearance.
Public Communications Team (JIC)—This team included public
information officers from the MINSA, PAHO, CDC, and the
Presidential Press Office. This function allowed the MINSA to
exert more control over health information, news releases, and
press briefings. After the real cause and the potential scope of
the outbreak were discovered, an unprecedented social mobi-
lization effort was launched to reach communities across the
republic, many with no access to radio or television, using avail-
able community resources. The massive media communications
campaign targeted common traff ic areas such as bus stations
and markets, and included pictures of the bottles of medications
implicated. In addition, radio and television spots were pur-
chased during popular programming.
Clinical Team—The joint clinical team consisted of a neurolo-
gist, nephrologists, and medical officers responsible for develop-
ing and implementing clinical measures and treating patients.
The team coordinated consultation with external agencies or
specialists in treating patients exposed to diethylene glycol. The
clinical team also was responsible for collecting post-mortem
samples. The team continued to monitor the condition of many
of the survivors and to ascertain the short- and long-term effects
of DEG on certain patients.20
Logistics
The events logistics section was staffed mostly by MINSA per-
sonnel. The logistics section arranged for the collection, storage,
and transportation of supplies and equipment and manage-
ment of the thousands of biological and material samples col-
lected. They provided communication equipment including cell
phones and two-way radios, and were responsible for managing
the motor pool of vehicles assigned to the various teams. The
section also coordinated with other agencies to establish sites
around the country that would allow people to safely dispose
of medications. These collection sites were set up in police and
fire stations, schools, and other conveniently located places. This
coordination required considerable effort because many commu-
nities were located in remote areas.
Finance/Administration
The finance/administrative section was responsible for: (1) coor-
dinating authorizations and funding for purchases related to
medical equipment, supplies, and meals; (2) working with cus-
toms clearance; and (3) coordinating court orders for access to
facilities, etc.
222 Coordinating Public Health Response
Prehospital and Disaster Medicine Vol. 26, No. 3
Hospital Response Actions Initiated
Recent emergent disease threats, such as the outbreak of
severe acute respiratory syndrome (SARS), have underscored
the need for more cautiously managing outbreaks of unknown
etiologies.21, 22 As a result, and in the absence of a definitive
diagnosis, Panamanian authorities implemented command and
control measures similar to those used in the Hospital Incident
Command System (HICS).23 Until a definitive diagnosis was
established, the main objective was to prevent the illness from
spreading among healthcare providers, patients, and their fami-
lies. These actions highlighted the increased preparedness of
hospital systems for controlling disease in healthcare institutions
in the post-SARS era.24,25
Among the measures implemented were:
1. Representation of the various healthcare systems in UC
structure;
2. Designation of a national hospital as the primary receiving
center for suspected cases;
3. Establishment of a special isolation ward staffed with per-
sonnel for effectively monitoring and providing care;
4. Enforcement of mandatory use of personal protective
equipment by all hospital visitors and ambulance and
patient transport personnel; and
5. Enforcement of hygiene practices with special emphasis in
facility infection control measures, such as hand washing,
linen disposal, and regular disinfection of common sur-
faces in public hospital areas.
Discussion
Advantages of Using UC
Perhaps the most significant advantages of using a UC system
are those attributes that are characteristically inherent to ICS in
general, and as such, the UC was flexible and scalable accord-
ing to the demands of this outbreak. The UC system provides
a unity of command often missing in recent, multi-national
disaster responses, such as that after the Indian Ocean tsunami
that struck Indonesia in 2004.
26 The use of a UC organiza-
tional system allowed for formal coordination of national and
international assets by providing a formal structure for integra-
tion. The autonomy of the host Government was preserved and
Panamanian officials retained final authority over all response
investigations and interventions. The use of one integrated UC
allowed for maximum efficiency, since it provided common
“line” (logistics, administrative, finance, and planning) support
for all operational functions reducing the need for redundant
supply chains and administrative procedures. Unity of command
also allowed for a more effective accounting and retained a man-
ageable span of control of 3–5 subordinates for each of the sup-
port sections and operational teams. As a result, the UC chain
of command was clear and succinct. All response actions, media
reports, and public communications were directed through the
government of Panama’s UC structure using the JIC concept.
Finally, operational delays while waiting for team assignments
due to unfamiliarity with the national system were minimized
because the UC provided a framework flexible enough to quickly
assign personnel to where they were needed most urgently.
The coordination of multiple separate national and insti-
tutional systems under one UC posed certain challenges dur-
ing this outbreak. One of these challenges included managing
and directing information flow. Partner agencies were not
accustomed to sharing information through common, unified
channels, and required some degree of monitoring and prompt-
ing. Other issues related to patient confidentiality and forensic
evidence challenged the ability of the organizational structure to
compartmentalize and protect sensitive data while still offering
partners transparent and seamless access to information. Finally,
for obvious reasons, issues related to national sovereignty and
international relations were difficult to address by means of
the UC. In this case, Panamanian law regulating international
importation and pharmaceutical use of DEG came into discus-
sion, and these issues were processed best internally by the host
Government. Other challenges for applying a UC system were
related to scalability due to the finite amount of resources avail-
able to the host government at any given time. Although this
was not the case in this disaster, there are historical examples
when the sheer size and consequences of the event can exceed a
host government’s capacity to lead the response. While effective
in establishing unity of command and an effective span of con-
trol for operations using a standardized approach, this particular
application of UC does not offer an extremely high degree of
scalability for large disasters that may require coordination of
literally thousands of response and aid workers. Finally, the UC
alone also does not effectively address the need for an efficient
processing of funding and in-kind donations from international
humanitarian organizations.
The Health Cluster (HC) approach to managing public
health emergencies has been met with variable degrees of suc-
cess.9 The most obvious advantage of using the HC system in
disaster response is that of its enormous range for accommodat-
ing multinational resources. The system may be used to coor-
dinate among a handful of stakeholders up to that of several
hundred responses and multiple relief organizations. On the
other hand, this lack of an appropriate span of control also cre-
ates challenges. These challenges included personnel tasking
and the tracking of multiple organizations. This may create a
diff icult operational environment that promotes redundancy
or clustering in common areas of interest (e.g., needs assess-
ments), which may result in unmet needs.27 Perhaps the most
signif icant challenge for the HC approach is the inherent lack
of legal mandate and authority for regulation and enforcement
of critical elements for a coordinative action in contrast to tra-
ditional ICS, where authority is centered with the local juris-
diction. This relative weakness in the HC system may affect
the system’s ability to carry out traditional incident command
basic principles such as speaking with one voice, prioritization
of critical tasks, and accountability.
Conclusions
The ICS is a widely accepted system for operating during large
disasters. Public and fire safety agencies, emergency services,
and the military all have used the ICS successfully during emer-
gency operations. This paper describes how a number of public
health organizations joined together to work under a common
operational framework in Panama. The framework allowed
for increased speed in establishing and integrating a number
of multinational teams. During this outbreak investigation, an
ICS-like system utilizing a UC provided an effective and effi-
cient manner to organize and integrate personnel and resources
from multiple countries into a common operational framework.
This experience with the ICS during this outbreak investigation
demonstrates that the ICS can be used effectively during pub-
lic health emergencies as well. The UC concept also improved
Cruz, Keim, Schier, et al 223
June 2011 Prehospital and Disaster Medicine
14. A ntecedentes. I nstituto Conm emorativo Gorg as de Estud ios de la Salud. Ava ilable
at http://www.gorgas.gob.pa/. Accessed October 2007.
15. Bayard V, Kitsutani PT, Barria EO, Ruedas LA, Tinn in DS, Muñoz C, de Mosc a
IB, Guerrero G, Ka nt R, Garcia A, Caceres L, Gracio FG, Quiroz E, de Castillo
Z, Ar mien B, Libel M, Mills JN, Kha n AS, Nichol ST, Rollin PE, Ksiazek TG,
Peters CJ: Outbreak of Hantavirus pulmonary synd rome, Los Sa ntos, Panama,
1999–2000. Emerg Infect Dis 2004;10(9):1635–1642.
16. [US] Centers for Disea se Control and Prevention. Update: Cholera—Western
Hemisphere, 1991. MMWR 1991;40 (49):86 0.
17. Organización Panamericana de la Salud/Organización Mundial de la Salud:
Panamá. Available at http://ww w.new.paho.org/pan. Accessed July 2011.
18. M ignone AT, Davidson R : Public hea lth respons e actions and t he use of emergenc y
operations centers. Prehosp Disaster Med 2003;18(3):217–218.
19. Panamá , Sistema Nacional de Protección Civil (SINA PROC). Available at http://
ww w.sinaproc.gob.pa/. Accessed Aug ust 2007.
20. Schier JG, Con klin L , Saboga l R, Dell ’Aglio D, Sanchez C, Sej var J: Medical
toxicology and public health— Update on research and activities at the Centers for
Disease Control and Prevention and the Agency for Toxic Substance s and Disease
Registry. J Med Toxicol 2008;1;40–42.
21. Weber DJ, Rutala WA: Risk and prevention of nosocom ial transmission of rare
zoonotic disease s. Clinic Infect Dis 2001;32:446–456.
22. Varia M, Wilson S, Sarwa l S: Invest igation of a nosocomial outbreak of severe
acute respiratory syndrome (SARS) in Toronto, Canada. CAMJ 2004;170(6):927.
23. Za ne R, Prestipi no AL: Implement ing the hospita l emergency i ncident system : An
integrated delivery system’s experience. Prehosp Di saster Med 2004;19(4):311–317.
24. Shaw K: The 2003 SA RS outbrea k and its impac t on infect ion control prac tices.
Public Health 2006;120:8–14.
25 . Lo ut f y M R, Wal l in gt on T , Ru tl ed ge T, M ed er sk i B , Ro se K, Kw ole k S , M cR it ch ie
D, Ali A , Wolff B, White D, Glassman E, Ofner M, Low DE , Berger L, McGeer
A, Wong T, Baron D, Berall G: Hospital preparedness and SARS. Emerg Infect
Dis 2004;10:771–776.
26. The United Nat ions Children’s Fund (UNICEF ): 2004 Indian Ocean ea rthquake
and tsunami: Lessons lear ned. Available at http: //www.unicef.org/har08/index_
tsunami.html. Accessed Ju ly 2010.
27. Deitchman S: What have we learned?—Needs ass essment. Prehosp Disaster Med
2005;20(6):468–470.
communications among the agencies and teams and through the
JOC, created a focal point for Panamanian leadership to obtain
timely, consistent information about cases and maintain situ-
ational awareness of all teams’ activities.
Public health agencies should be familiar with the prin-
ciples of ICS and be prepared to initiate such a system early
in multidisciplinary public health responses, such as outbreak
investigations. Before disasters occur, national governments
should consider planning for the adoption of a UC system as
part of their preparedness activities. Furthermore, the use of a
UC-based system should empower local decision-makers with
the ability to locally manage a large–scale emergency or disaster
response, integrate international resources, and maintain self-
governance or autonomy at the same time. The UC–based sys-
tem provides both government and public health agencies with
options for managing simple or complex emergencies.
References
1. International Commission on Inter vention and State Sovereignty. The
Responsibility to Protect, Report of the International Commission on Intervention
and State S overeignt y (ICISS), December 2001. Avai lable at http://www.ic iss.ca/
pdf/Commission-Report.pdf. Accessed June 2010.
2. The Sphere Project: Sphere Handbook. The Sphere Project, Humanitarian
Standa rds in Disaster Response, 200 4. Available at ww w.sphereprojec t.org/.
Accessed on June 2010.
3. Federal Emergency Management A gency: T he National Incident Management
System Incident Comma nd System. Ava ilable at ht tp://ww w.fema.gov/pd f/
emergenc y/nims/N IMS_core.pdf. Accessed Aug ust 2009.
4. Kim-Ferley RJ, Celentano J T, Gunter C, Jones J W, Stone RA, A ller RD,
Mascola L, Grisgsby SF, Fielding GE: Standard ized emergency management
system and response to a smallpox emergency. Prehosp Disaste r Med 2003;18(4):
313–32 0.
5. Cruz-Vega F, Sun C, Brink B, Bugslag R, Gonzalez Del Castillo B, Hastings
P, Kipor GV, Lee SW, Lo CB, Poles L , Robinson P, Ronqui llo EL, Staña J,
Sydor J, Thani H: 5th Asia-Pacific C onference on Disaster Med icine. Theme 6:
Multidisciplina ry team interaction: Summar y and action plan. Prehosp Disaster
Med 2001;16(1):39–41.
6 . Bradt DA, D rumm ond CM: Profe ssiona lizat ion of dis aster med icine —An app raisa l
of criterion-referenced qualifications. Prehosp Disaster Med 2007;22(5):360–368.
7. Nelson C, Lurie N, Wasser man J, Zahowski S: Conceptualizing and defin ing
public health emergency preparedness. Am J Public Health 2007;97:S9–11.
8. Christen H, Maniscalco P: The EMS Incident Management System. Upper Saddle
River, N Y: Prentice-Hall, 1998.
9. The World Health Organization (W HO): Health Cluster Guide. Ava ilable at
ht tp:// ww w.who. int/ hac /glob al_ hea lth _clu ster/gu ide /en/i ndex .ht ml. A cces sed
August 2010.
10. Rent z ED, Lewis L , Mujica OJ, Barr DB, Sc hier JG, Weerasek era G, Kuklen yik P,
Mc Geeh in M , Ost erlo h J, Wa msle y J, Wa shi ngto n L, All eyn e C, S osa N , Mot ta J,
Rubin C: Outbreak of acute renal fai lure in Panama in 2 006: A case-control study.
Bulletin of the World Health Organiz ation 2008;86:749–756.
11. Contraloría Genera l de la Republ ica/Dirección de Estadística y Censo: Panamá
en Cifras 20032007. Available at http://www.contraloria.gob.pa/dec/cuadros.
aspx?ID=170302. Accessed July 2011.
12. Republica de Panamá Ministerio de Sa lud. Available at http://www.mi nsa.gob.
pa/. Accessed August 2 007.
13. Caja de Seguro Social, Pana má. Available at http://www.css.org.pa/. Accessed
August 2007.
... Various versions of ICS (including the United Nation cluster system and the hospital ICS) have increasingly been recognized among public health agencies and healthcare settings as effective systems for organizing public health emergency responses, including disease outbreaks. [4][5][6][7][8][9] Under the ICS, operations and logistics sections fall within the general staff functions (Figure 1). These sections are fundamental to the overall performance of the response and to successful accomplishment of the objectives as established by the incident commander or incident command (IC). ...
... 5,6,20-22 ICS has been used during core public health operations ranging from organizing toxicological and infectious disease outbreak investigations, responses to a pandemic, vaccinations campaigns, and natural disasters. 8,9,[23][24][25][26][27][28][29][30] Given this record of success, international public health agencies that provide operations and logistical support might want to consider providing basic ICS and specific function (logistics, operations, etc) training for staff. ...
Article
Hosting an international outbreak response team can pose a challenge to jurisdictions not familiar with incident management frameworks. Basic principles of team forming, organizing, and executing mission critical activities require simple and flexible communication that can be easily understood by the host country's public health leadership and international support agencies. Familiarity with incident command system principles before a public health emergency could save time and effort during the initial phases of the response and aid in operationalizing and sustaining complex field activities throughout the response. The 2009 initial outbreak of H1N1 in Mexico highlighted the importance of adequately organizing and managing limited resources and expertise using incident management principles. This case study describes logistical and operational aspects of the response and highlights challenges faced during this response that may be relevant to the organization of public health responses and incidents requiring international assistance and cooperation.
... Various versions of ICS (including the United Nation cluster system and the hospital ICS) have increasingly been recognized among public health agencies and healthcare settings as effective systems for organizing public health emergency responses, including disease outbreaks. [4][5][6][7][8][9] Under the ICS, operations and logistics sections fall within the general staff functions (Figure 1). These sections are fundamental to the overall performance of the response and to successful accomplishment of the objectives as established by the incident commander or incident command (IC). ...
... 5,6,20-22 ICS has been used during core public health operations ranging from organizing toxicological and infectious disease outbreak investigations, responses to a pandemic, vaccinations campaigns, and natural disasters. 8,9,[23][24][25][26][27][28][29][30] Given this record of success, international public health agencies that provide operations and logistical support might want to consider providing basic ICS and specific function (logistics, operations, etc) training for staff. ...
Article
Full-text available
Hosting an international outbreak response team can pose a challenge to jurisdictions not familiar with incident management frameworks. Basic principles of team forming, organizing, and executing mission critical activities require simple and flexible communication that can be easily understood by the host country's public health leadership and international support agencies. Familiarity with incident command system principles before a public health emergency could save time and effort during the initial phases of the response and aid in operationalizing and sustaining complex field activities throughout the response. The 2009 initial outbreak of H1N1 in Mexico highlighted the importance of adequately organizing and managing limited resources and expertise using incident management principles. This case study describes logistical and operational aspects of the response and highlights challenges faced during this re-sponse that may be relevant to the organization of public health responses and incidents requiring international assis-tance and cooperation.
... We have seen that an organized response is crucial to controlling and effectively responding to emergency incidents and saving lives. [10][11][12][13][14][15] The ICS is a fundamental component of the NIMS that serves as a management tool, implemented during disasters and emergency responses to organize and coordinate response efforts. 16 At FDA, NIMS implementation and training are led by the Office of Emergency Management (OEM), which helps ensure that the agency is incorporating NIMS into emergency response plans, procedures, and policies. ...
Article
The Food Safety Modernization Act mandates building a national Integrated Food Safety System, which represents a seamless partnership among federal, state, local, territorial, and tribal agencies. During multistate foodborne illness outbreak investigations, local and state partners, the Centers for Disease Control and Prevention, the United States Food and Drug Administration (FDA), or the United States Department of Agriculture Food Safety Inspection Service, depending on the regulated food product, become engaged and assist in coordinating the efforts between partners involved and determine the allocation of resources. The FDA Center for Food Safety and Applied Nutrition (CFSAN) Office of the Coordinated Outbreak Response and Evaluation (CORE) Network coordinates foodborne illness outbreak surveillance, response, and post-response activities related to incidents involving multiple illnesses linked to FDA-regulated human food, dietary supplements, and cosmetic products. FDA has implemented the National Incident Management System (NIMS) Incident Command System (ICS) principles across the agency to coordinate federal response efforts, and CORE has adapted NIMS ICS principles for the emergency management of multistate foodborne illness outbreaks. CORE's implementation of ICS principles has provided several benefits to the operational cycle of foodborne illness outbreak investigations, including establishing a consistent, standardized, and transparent step-by-step approach to outbreak investigations. ICS principles have been instrumental in the development of a national platform for rapid and systematic laboratory, traceback, and epidemiologic information sharing, data analysis, and decision-making. This allows for partners across jurisdictions to reach a consensus regarding outbreak goals and objectives, deploy resources, and take regulatory and public health actions.
... The Incident command system is a widely accepted system for operations during large disasters. During an acute renal failure outbreak in Panama, an ICS-like system provided an effective and efficient manner to organize and integrate personnel and resources from multiple countries into a common operational framework for control disease [19]. An effective and flexible system is crucial for an effective disaster response. ...
Article
Full-text available
Background: In 2011, Thailand was affected by the one of the worst flood disasters in recent times. Hospitals in Thailand were faced with the challenge of managing the health impacts from this natural disaster. The purpose of this study was to assess flood disaster preparedness among hospitals in the central region of Thailand. Methods: A survey questionnaire was given to twenty-seven key people responsible for hospital disaster preparedness that experienced disruptions to health services (severely, moderately and slightly) during the flood disaster in 2011 in the central region of Thailand. Results: Of the twenty-four participating hospitals, not one had satisfied the standards in all the dimensions of flood disaster preparedness. All respondent hospitals were deficiently prepared with regard to surge capacity, the management of healthcare services and the management of the supporting systems. The availability of supplies and equipment were found to be in place but preparations were found to be inadequate in organizing staff at all participating hospitals. Trained staff members regarding disaster response were reported to be present in all respondent hospitals. Hospitals that experienced slightly disruptions to their health services did not elect to do any exercises to meet the set standards. None of the hospitals that experienced slightly disruptions to their health services performed any evaluation and improvement in terms of disaster preparedness. Conclusions: Many hospitals were not up to standard in terms of disaster preparedness. Hospitals should prioritize disaster preparedness to fulfill their responsibility during crisis situations and improve their flood disaster preparedness.
Article
Full-text available
In September 2006, a Panamanian physician reported an unusual number of patients with unexplained acute renal failure frequently accompanied by severe neurological dysfunction. Twelve (57%) of 21 patients had died of the illness. This paper describes the investigation into the cause of the illness and the source of the outbreak. Case-control and laboratory investigations were implemented. Case patients (with acute renal failure of unknown etiology and serum creatinine > 2 mg/dl) were individually matched to hospitalized controls for age (+/- 5 years), sex and admission date (< 2 days before the case patient). Questionnaire and biological data were collected. The main outcome measure was the odds of ingesting prescription cough syrup in cases and controls. Forty-two case patients and 140 control patients participated. The median age of cases was 68 years (range: 25-91 years); 64% were male. After controlling for pre-existing hypertension and renal disease and the use of angiotensin-converting enzyme inhibitors, a significant association was found between ingestion of prescription cough syrup and illness onset (adjusted odds ratio: 31.0, 95% confidence interval: 6.93-138). Laboratory analyses confirmed the presence of diethylene glycol (DEG) in biological samples from case patients, 8% DEG contamination in cough syrup samples and 22% contamination in the glycerin used to prepare the cough syrup. The source of the outbreak was DEG-contaminated cough syrup. This investigation led to the recall of approximately 60 000 bottles of contaminated cough syrup, widespread screening of potentially exposed consumers and treatment of over 100 affected patients.
Article
Full-text available
On May 23, 2003, Toronto experienced the second phase of a severe acute respiratory syndrome (SARS) outbreak. Ninety cases were confirmed, and >620 potential cases were managed. More than 9,000 persons had contact with confirmed or potential case-patients; many required quarantine. The main hospital involved during the second outbreak was North York General Hospital. We review this hospital's response to, and management of, this outbreak, including such factors as building preparation and engineering, personnel, departmental workload, policies and documentation, infection control, personal protective equipment, training and education, public health, management and administration, follow-up of SARS patients, and psychological and psychosocial management and research. We also make recommendations for other institutions to prepare for future outbreaks, regardless of their origin.
Article
The smallpox virus is a high-priority, Category-A agent that poses a global, terrorism security risk because it: (1) easily can be disseminated and transmitted from person to person; (2) results in high mortality rates and has the potential for a major public health impact; (3) might cause public panic and social disruption; and (4) requires special action for public health preparedness. In recognition of this risk, the Los Angeles County Department of Health Services (LAC-DHS) developed the Smallpox Preparedness, Response, and Recovery Plan for LAC to prepare for the possibility of an outbreak of smallpox. A unique feature of the LAC-DHS plan is its explicit use of the Standardized Emergency Management System (SEMS) framework for detailing the functions needed to respond to a smallpox emergency. The SEMS includes the Incident Command System (ICS) structure (management, operations, planning/intelligence, logistics, and finance/administration), the mutual-aid system, and the multi/interagency coordination required during a smallpox emergency. Management for incident command includes setting objectives and priorities, information (risk communications), safety, and liaison. Operations includes control and containment of a smallpox outbreak including ring vaccination, mass vaccination, adverse events monitoring and assessment, management of confirmed and suspected smallpox cases, contact tracing, active surveillance teams and enhanced hospital-based surveillance, and decontamination. Planning/intelligence functions include developing the incident action plan, epidemiological investigation and analysis of smallpox cases, and epidemiological assessment of the vaccination coverage status of populations at risk. Logistics functions include receiving, handling, inventorying, and distributing smallpox vaccine and vaccination clinic supplies; personnel; transportation; communications; and health care of personnel. Finally, finance/administration functions include monitoring costs related to the smallpox emergency, procurement, and administrative aspects that are not handled by other functional divisions of incident command systems. The plan was developed and is under frequent review by the LAC-DHS Smallpox Planning Working Group, and is reviewed periodically by the LAC Bioterrorism Advisory Committee, and draws upon the Smallpox Response Plan and Guidelines of the Centers for Disease Control and Prevention (CDC) and recommendations of the Advisory Committee on Immunization Practices (ACIP). The Smallpox Preparedness, Response, and Recovery Plan, with its SEMS framework and ICS structure, now is serving as a model for the development of LAC-DHS plans for responses to other terrorist or natural-outbreak responses.
Article
Americans are increasingly exposed to exotic zoonotic diseases through travel, contact with exotic pets, occupational exposure, and leisure pursuits. Appropriate isolation precautions are required to prevent nosocomial transmission of rare zoonotic diseases for which person-to-person transmission has been documented. This minireview provides guidelines for the isolation of patients and management of staff exposed to the following infectious diseases with documented person-to-person transmission: Andes hantavirus disease, anthrax, B virus infection, hemorrhagic fevers (due to Ebola, Marburg, Lassa, Crimean-Congo hemorrhagic fever, Argentine hemorrhagic fever, and Bolivian hemorrhagic fever viruses), monkeypox, plague, Q fever, and rabies. Several of these infections may also be encountered as bioterrorism hazards (i.e., anthrax, hemorrhagic fever viruses, plague, and Q fever). Adherence to recommended isolation precautions will allow for proper patient care while protecting the health care workers who provide care to patients with known or suspected zoonotic infections capable of nosocomial transmission.
Article
Multidisciplinary team interaction has become a commonplace phrase in the discussion of disaster response. Theme 6 explored multidisciplinary team interactions and attempted to identify some of the key issues and possible solutions to the seemingly intractable problems inherent in this endeavour. Details of the methods used are provided in the introductory paper. The Cochairs moderated all presentations and produced a summary that was presented to an assembly of all of the delegates. The Cochairs then presided over a workshop that resulted in the generation of a set of Action Plans that then were reported to the collective group of all delegates. Main points developed during the presentations and discussion included: (1) promotion of multidisciplinary collaboration, (2) standardization, (3) the Incident Command System, (4) professionalism, (5) regional disparities, and (6) psychosocial impact. Action plans recommended: (1) a standardized template for Needs Assessment be developed, implemented, and applied using collaboration with international organizations, focusing on needs and criteria appropriate to each type of event, and (2) team needs assessments be recognized for local responses and for determination of when international assistance may be required, for planning a command system, and for evaluating the psychosocial impact. There is a clear need for the development of standardized methods for the assessment of needs, development and implementation of a command structure, and for appreciation of regional differences and the psychosocial impact of all interventions.
Article
Severe acute respiratory syndrome (SARS) was introduced into Canada by a visitor to Hong Kong who returned to Toronto on Feb. 23, 2003. Transmission to a family member who was later admitted to a community hospital in Toronto led to a large nosocomial outbreak. In this report we summarize the preliminary results of the epidemiological investigation into the transmission of SARS between 128 cases associated with this hospital outbreak. We collected epidemiologic data on 128 probable and suspect cases of SARS associated with the hospital outbreak, including those who became infected in hospital and the next generation of illness arising among their contacts. Incubation periods were calculated based on cases with a single known exposure. Transmission chains from the index family to hospital contacts and within the hospital were mapped. Attack rates were calculated for nurses in 3 hospital wards where transmission occurred. The cases ranged in age from 21 months to 86 years; 60.2% were female. Seventeen deaths were reported (case-fatality rate 13.3%). Of the identified cases, 36.7% were hospital staff. Other cases were household or social contacts of SARS cases (29.6%), hospital patients (14.1%), visitors (14.1%) or other health care workers (5.5%). Of the 128 cases, 120 (93.8%) had documented contact with a SARS case or with a ward where there was a known SARS case. The remaining 8 cases without documented exposure are believed to have had exposure to an unidentified case and remain under investigation. The attack rates among nurses who worked in the emergency department, intensive care unit and coronary care unit ranged from 10.3% to 60.0%. Based on 42 of the 128 cases with a single known contact with a SARS case, the mean incubation period was 5 days (range 2 to 10 days). Evidence to date suggests that SARS is a severe respiratory illness spread mainly by respiratory droplets. There has been no evidence of further transmission within the hospital after the elapse of 2 full incubation periods (20 days).
Article
In the wake of 11 September 2001, many public health agencies are reassessing their institutional capabilities and procedures to respond to mass-casualty incidents involving weapons of mass destruction. Prior to the fall of 2001, planning by the public health and other sectors addressed more conventional or naturally occurring events such as earthquakes, hurricanes, tornados, and chemical spills, although attacks with weapons of mass destruction were a growing concern. While the nature of natural versus intentional events differs, the management and coordination of response activities to them follows the same incident command system. A major lesson learned during the response operations to the 11 September 2001 attacks in New York City was the value of disaster planning, conducting exercises, and developing relationships among the various response agencies. Although New York City's physical Emergency Operations Center (EOC) at 7 World Trade Center was destroyed in the attack, the medical and health response community was able to react effectively to the possibility of mass casualties as well as to the more usual needs. This was enabled by the pre-existing relationships that had been developed between city, state, federal, and non-governmental agencies while planning and exercising for such events and their aftermaths.
Article
The smallpox virus is a high-priority, Category-A agent that poses a global, terrorism security risk because it: (1) easily can be disseminated and transmitted from person to person; (2) results in high mortality rates and has the potential for a major public health impact; (3) might cause public panic and social disruption; and (4) requires special action for public health preparedness. In recognition of this risk, the Los Angeles County Department of Health Services (LAC-DHS) developed the Smallpox Preparedness, Response, and Recovery Plan for LAC to prepare for the possibility of an outbreak of smallpox. A unique feature of the LAC-DHS plan is its explicit use of the Standardized Emergency Management System (SEMS) framework for detailing the functions needed to respond to a smallpox emergency. The SEMS includes the Incident Command System (ICS) structure (management, operations, planning/intelligence, logistics, and finance/administration), the mutual-aid system, and the multi/interagency coordination required during a smallpox emergency. Management for incident command includes setting objectives and priorities, information (risk communications), safety, and liaison. Operations includes control and containment of a smallpox outbreak including ring vaccination, mass vaccination, adverse events monitoring and assessment, management of confirmed and suspected smallpox cases, contact tracing, active surveillance teams and enhanced hospital-based surveillance, and decontamination. Planning/intelligence functions include developing the incident action plan, epidemiological investigation and analysis of smallpox cases, and epidemiological assessment of the vaccination coverage status of populations at risk. Logistics functions include receiving, handling, inventorying, and distributing smallpox vaccine and vaccination clinic supplies; personnel; transportation; communications; and health care of personnel. Finally, finance/administration functions include monitoring costs related to the smallpox emergency, procurement, and administrative aspects that are not handled by other functional divisions of incident command systems. The plan was developed and is under frequent review by the LAC-DHS Smallpox Planning Working Group, and is reviewed periodically by the LAC Bioterrorism Advisory Committee, and draws upon the Smallpox Response Plan and Guidelines of the Centers for Disease Control and Prevention (CDC) and recommendations of the Advisory Committee on Immunization Practices (ACIP). The Smallpox Preparedness, Response, and Recovery Plan, with its SEMS framework and ICS structure, now is serving as a model for the development of LAC-DHS plans for responses to other terrorist or natural-outbreak responses.