Environmental Health Officers in the

2004 Hurricane Response

A report to the EHOPAC Readiness Subcommittee

CDR Tim Radtke CAPT Jan Manwaring

March 2005

Contents

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 General Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Special Needs Shelter Assignment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Mega-shelter Assignment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 State-wide Environmental Health Office Support . . . . . . . . . . . . . . . . . . . . 8 Additional Photographs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Thanks to the following reviewers: CAPT Craig Shepard, CDR Mark Miller, CDR Larry Cseh, CDR Duane Kilgus, LCDR Brian Hroch, LCDR Chris Kates, LT Lisa Delaney, LT Elizebeth Slawinski

2

INTRODUCTION: The hurricanes of 2004 (Charlie, Francis, Ivan, and Jeanne) created immense public health needs involving flooded areas, utility failures, food safety hazards, structural damage, and displaced residents throughout the State of Florida. As a result, the health departments and residents in these areas were overwhelmed with disaster response efforts. The role of the Environmental Health Officer in support of state health department operations was a crucial and successful component in the U.S. PHS response. 49 EHO's were deployed throughout the September and October response. The flexibility of our officers to take on the changing demands of the deployment lead to the success of the mission. The deployment consisted of three components: the special needs shelter assignments; the mega-shelter assignments at the Orange County Convention Center; and State-wide Environmental Health Office assignments. Past efforts of the EHOPAC and senior officers in showing the value of EHO's in emergency responses was evident in OFRD assignment of EHO's to each of the six medical strike teams. The FEMA Disaster Field Office (DFO) received numerous complements not only from team leaders but also from state contacts concerning the unexpected but greatly needed asset of the teams. The scope of the initial EHO assignment was to support the special needs shelters in the six counties on the eastern coast of Florida most affected by Hurricanes Jeanne and Charlie. PHS support efforts at each of these shelters varied from full PHS operation including 24 hour staffing of shelters with more than 45 patients to very limited assistance in a shelter with less than ten patients. Officers also staffed satellite clinics in various areas. EHO oversight in these shelters and clinics included inspection of food service facilities, general infection control measures, facility inspection for safety and health deficiencies, drinking water assessments, sewage and solid waste handling and disposal. Issues of medical waste disposal, medical gas use and storage were also addressed by EHO's. Initial EHO shelter work was completed within the first few days with ongoing oversight for the duration of the special needs shelter operations. EHOs at these shelters took the initiative in leading other tasks such as coordinating the disinfection of 600 beds from various shelters with the County Sheriff using detention center laborers; serving as County ESF #8 liaisons at the local Emergency Operations Centers; and acting as deployment photographers and historians. EHO's were also assigned to non-category specific roles during the deployment. They served in leadership roles as a Medical Strike Team Leader and as members of the SERT. Several EHO's served with officers from other categories as public information officers and community relations specialists working with FEMA in residential areas. During the special needs shelter operations, the medical strike team leader in Brevard County identified the need for assisting the Brevard County Environmental Health Department director. Because of this need for environmental health assistance, officers from another medical team were transferred to assist in Brevard County. Additionally, two of the pharmacists had a background in food and water safety issues and were able to be assigned to this operation and worked with experienced EHO's. At the peak of our

3

Brevard EOC assignment, 5 officers were assigned to assist with environmental health issues. Duties included follow up with boil water advisory recommendations, restaurant inspections, complaints, drinking water samples, wastewater evaluations, post disaster assessments at daycare centers, nursing homes and limited food service establishments. The EHO's from the other medical teams contacted their environmental health offices and were able to expand the scope of their deployment to areas where their expertise was most needed. Captain Malloy (IHS EHO) was a member of the Emergency Response Team -Advanced (ERT-A) and also coordinated with the State Environmental Health Office. After seeing the role EHO's could fill in assisting the County Environmental Health Offices, the State provided us with a list of additional counties that needed assistance if we had available officers. It was made clear to the State that the EHO role was to assist with disaster operations, and not be used for increasing their routine inspection numbers for their offices. The state government's departmental jurisdiction was an issue that arose during the deployment. In the State of Florida, general restaurant food service operations are regulated under the Florida Department of Agriculture and Consumer Services. The Department of Health and the Emergency Management Division was in communication with the Department of Agriculture to ensure they were aware of our capability to assist with restaurant inspections. Some officers participated in general information distribution at retail food service establishments, but PHS assistance was not requested for this role. Individual DHHS agencies had officers deployed and working independently from OFRD. This became an issue when the State of Florida was working with the agency in developing an Action Request Form to fill a need for environmental health support. The DHHS Incident Commander (IC) was not aware of the pending request nor was the Secretary's Operation Center. A process should be established to ensure all DHHS assets are tracked and coordinated through the DHHS IC. The Orlando Mega-shelter was requested by the State of Florida because of the projected path of hurricane Ivan. Hurricane Ivan was projected to hit the Florida Keys and then travel north down the center of the state. The shelter was proposed to hold 2000-3000 special needs patients and personal care givers. Because of this, tasking DHHS deployed 640 officers to the shelter. Once Hurricane Ivan changed its path, the shelter was never utilized to its original capacity, and it was determined that the DHHS assets could be reassigned. During the transition from the special needs shelter operations to the establishment of the Orlando Mega-shelter, the IC, Admiral Banks, gave permission to select all available EHO's for reassignment into the Environmental Health Offices where the state had requested assistance. At a time when the Mega-shelter was overstaffed and officers were looking for assignments, we were able to assign all available EHOs to counties in need. Using an on-site officer information database, developed by an EHO, all EHO's involved in the response were identified and contacted to determine their capability to be reassigned. Coordinating with the travel managers, we worked with the county offices to locate hotels for these officers. Travel arrangements were sketchy and

4

many times the travel personnel at the SOC could not locate a room for an officer outside of the Orlando area, but they allowed us to locate a room and report back to them. Officers' assignments were coordinated with the State Office of Environmental Health in Tallahassee. We emphasized the importance of staying in daily contact with officers in the field to ensure their safety and for them to report on pertinent issues. This was particularly important with the approach of new hurricanes. A mid-day call in was required along with an activity report at the conclusion of each day. The IC was updated twice daily on field activities. Several days following landfall of Hurricane Ivan, the Mega-shelter was inactivated and resources were shifted with incoming EHO's (predominantly from CDC) assigned to assist the panhandle counties. Seven EHO's deployed in response to hurricane Ivan in the panhandle counties of Escambia and Santa Rosa. Six of these officers were deployed through the Centers for Disease Control and Prevention with one deployed through OFRD. This hurricane response effort revealed both areas needing improvement and those that were very successful. A priority of the EHOPAC Environmental Health Readiness Subcommittee (EHRS) should be to work closely with OFRD in preplanning for the environmental component of emergency responses. In the planning process, OFRD must be aware that environmental health support will always be a primary need in any emergency response, especially during natural disasters. The following recommendations are long range goals from lessons learned during the hurricane response, that will ultimately result in better utilization of PHS assets in any disaster response. GENERAL RECOMMENDATIONS:

• EHOPAC EHRS should use an EHO skill survey or similar database as a method of determining areas of officers' expertise for deployment selection.

• EHOPAC EHRS should consider being involved in coordination with OFRD, CDC, or other OPDIVs on initial assignments of officers to ensure the appropriate expertise for each assignment.

• State Environmental Health Departments should be aware of the PHS EHO resources and should be a part of initial request in natural disaster response.

• EHOPAC should have an ongoing marketing strategy for making OFRD and state emergency coordinators and EH Directors aware of the capabilities for EHO's in the response planning phase.

• EHOPAC Emergency Response Subcommittee should coordinate base level training for all EHO's to be able to perform basic food, water, wastewater, solid waste, and general sanitation inspections during a response.

• Need for better coordination of environmental health resources from Agencies and DHHS IC particularly in environmental health.

• States have issues with internal jurisdictional boundaries relating to regulating food service establishments. The FL Division of Environmental Health does not

5

regulate retail food establishments. There should be a mechanism for informing all environmental health operations within the state of our response capability.

• The process for reimbursement of travel expenses should be evaluated and improved to ensure timeliness.

• Each officer should be equipped with a cell phone for deployments in the event of a rapid evacuation, for tracking officers, and for general communication.

• Basic field equipment should be available for deployments which should include such items as: food thermometer; chlorine test strips, water testing kit, and flashlight, work gloves, disposable camera, and first aid kit.

• Require the establishment of an EHO position on emergency response team - advance (ERT-A) to ensure that environmental health issues related to food, water, wastewater, solid waste, and general sanitation are addressed in the initial assessments. Being on the ERT-A and having a role in disaster response planning will enable faster response times for EHO's.

• The selection of a suitable deployment uniform should continue to be pursued. Limitations of the working khaki uniform were revealed during this deployment. Ideally, the uniform fabric would be durable and resist staining, while the footwear would be protective with lugged soles.

SPECIAL NEEDS SHELTER ASSIGNMENTS: Routine duty: A general environmental health assessment involving food service, drinking water, wastewater, solid waste, infection control and safety was conducted at each shelter. A report was written and the findings were shared with the shelter manager and the Brevard County ESF 8 Coordinator. All items identified during the assessment were corrected by the next day of operation. Additional checks were conducted thereafter to ensure sanitation and safety. In preparation for daily assessments at the Mega-shlter, EHO's developed a daily shelter operations inspection sheet to identify environmental health issues and track progress for correcting identified issues. The shelter operations inspection sheet is included as an attachment to this report and may serve as a guide for future disaster responses involving shelter operations.

Special assignments: EHOs took leadership in coordinating the sanitizing of over 600 cots/beds using labor provided by inmates from the Sheriff’s office. ESF#8 liaison at county emergency operations centers responding to calls and situations including: sewage releases, logistics requests from the special needs shelter, residents needing electrical power for their medical equipment.

Cot disinfection project

6

An EHO acted as the mission photographer. EHOs reviewed emergency operations plans. As demand for the clinical staff declined and the special needs shelter was down to less than 10 patients, the medical teams pulled out for reassignment to the mega-shelter operation in Orlando, while the EHO's continued assisting with the County Offices. MEGA-SHELTER ASSIGNMENT (ORANGE COUNTY CONVENTION CENTER): The EHO command was responsible for the Environmental Health assets throughout the State of Florida and the EHO/infection control responsibilities at the Mega-shelter. During the command structure organization, it was decided that infection control would fall under the command of environmental health. The infection control component consisted of 3 infection control nurses and a team of 4 CDC epidemiologists interested in creating a database of patient information. The EHO commander briefed the Safety Officer on aspects of safety that overlapped with infection control and environmental health. The command structure separated the EHO responsibility from the Safety Officers. The safety officer reported directly to the incident commander while EH/Infection Control was under Operations. We staffed an infection control nurse and EHO during the day shift at the shelter. Environmental health and infection control issues addressed at the shelter included the following:

Mega-Shelter at the Orange County Convention Center

• Held staff briefings on infection control for clinical staff on all shifts; • Addressed client (patient) cohorting/spacing based on patient needs; • Acquired and positioned hand washing stations; • Biohazard waste control - worked with logistics to contract with local company;

interim measures - ambulance service transported waste to hospital waste stream; • Food service sanitation oversight and food processing control; • Pest control oversight (birds, cockroaches, flies, etc); • Shower sanitation and accessibility oversight; • Disinfection of beds - coordinated with USFS on methods and proper

precautions; • Single case of GI distress - determined not to be food borne from shelter, EHO

monitored for additional cases and found none; • Participated in safety meetings and worked closely with safety officer.

7

EHO's working as Liaison Officers at the Disaster Field Office developed a database to track all DHHS personnel resources involved in the response. Prior to this, there was no mechanism for tracking officers. The Secretary's Operation Center and agencies were assuming that each group requesting assistance was tracking our staff. It wasn't until an EHO acting as a liaison officer at the Disaster Field Office in Orlando questioned the lack of command and control of the deployed staff with a hurricane projected to hit the area that the two EHO liaison officers started creating the database. This system was later used to demobilize and reassign assets from the Mega-shelter.

Successes: 1. Development of EH/Infection Control action plan helped us

focus on tasks. 2. Worked well with safety officers and officers from USFS.

3. Food service used pre-processed foods to minimize preparation on-site. For the most part they had good food handling practices and constantly monitored temperatures of foods. They were very responsive to corrective measures. 4. Quality of officers and their commitment to get tasks completed. 5. EH shelter inspection checklist. 6. Development of an on-site staffing database to track DHHS personnel and resources in the state.

Opportunities for improvement:

1. Have logistics arrange laundry, biohazard waste, food service, showers (wheelchair accessible) ready to go upon arrival.

2. Need for standard plans for blood borne pathogens, infection control, and food sanitation, facility EH checklists, etc.

3. Need copier and email access in admin area. 4. Need infectious disease screening of all clients (patients) and

caregivers and establish isolation or holding areas. 5. Need to locate patient area closer to bathroom facilities. 6. Need means of identifying which beds need disinfection. 7. Need 3 feet separation between cot/bed pairs during initial set-up. 8. Deployed personnel with illness should leave shelter immediately to

prevent possible spread of infection. 9. Consider organizationally combining Environmental health, safety,

and infection control. 10. Manage State-wide EHO assets under a separate authority.

STATE-WIDE ENVIRONMENTAL HEALTH OFFICE SUPPORT: Our officers were able to assist the State Environmental Health Office by evaluating establishments for food safety, water quality, general structural integrity, wastewater systems, general sanitation, and safety factors. They inspected day care centers, nursing homes, food establishments, emergency food distribution centers, schools, general populace shelters, and community water and wastewater systems. They were able to

8

relieve some of the environmental health inspectors that had been on duty without a break since hurricane Charlie. It was imperative to immediately visit the establishments that were without power for several days to address food, water, wastewater, and general sanitation issues, and to inform them of possible hazards when performing cleaning up operations after the storm. The actual numbers of inspections was not tallied for all officers but many teams reported "hundreds" of facility visits. The following is a tally of EHO inspections in some of the counties: Four EHO's working in Brevard County from September 13 through17 accomplished the following environmental health inspections/activities:

• 32 public water wells • 4 public water supplies • 4 schools/temporary shelters • 10 daycares/nursing homes • 3 food service operations

Two EHO's working in Martin County from September 16 through 18 accomplished the following environmental health inspections/activities:

• 6 mobile home parks • 4 schools • 6 food service operations

Seven EHO's working in Escambia County from September 21 through 29 (aftermath of hurricane Ivan) accomplished the following environmental health inspections/activities:

• 192 mobile home parks • 132 assisted living/day care centers • 102 temporary/limited food service operations • 19 food distribution sites • 10 water samples • 8 complaint investigations • 7 school cafeterias

Four EHO's working in Santa Rosa County from September 20 through 24 (aftermath of Hurricane Ivan) accomplished the following environmental health inspections/activities:

• 32 assisted living/day care centers • 25 temporary/limited food service operations • 5 food distribution sites • 7 complaint investigations • 3 school cafeterias

Two EHO's working in Seminole County from September 14 through 17 accomplished the following environmental health inspections/activities:

• 50 pool inspections • 100 water sampling kits • 102 daycare and mobile home park

9

Initial State-wide EHO assets: After seeing the impact of EHO's in Brevard County, Environmental health assets were drawn from all available EHO's in the hurricane disaster theater with the exception of those involved with the SERT and DFO assignments. Assignments of officers were coordinated with the Deputy Director of Environmental Health for the State of Florida, and needs for assistance were prioritized. During this time, the mega shelter operation was gearing up and the pharmacists assisting with environmental health were reassigned to command pharmacy operations. The DHHS Incident Commander - (Admiral Banks) was briefed twice daily on the status of the environmental health response throughout the State. During mega-shelter operations, the Operations Chief was also updated several times per day. The State was in process of filing an ARF for 20 EHO's to be ready to respond to hurricane Ivan. This request was coordinated directly with the Centers for Disease Control and Prevention. Officers were assigned to the following counties during the deployment (Sept 7 - Oct 14)

Location Officers Brevard 5 DeSoto 3 St Lucie 2 Martin 2 Volusia 1 Palm Beach 2 Seminole 2 Lake 2 St. Augustine 4 Santa Rosa 4 Escambia 7 Orlando 12

EHO's teamed up with County Health Department Public Health Nurses and traveled to homes throughout the Counties providing residents post hurricane/disaster informational

10

guidance documents, county emergency numbers, and special needs applications. In addition, supplies were provided to hurricane victims including bottled water, mosquito repellent, mosquito larvacide, chlorine test strips, and waterless sanitizing gel. The communities assisted included mobile home parks and communities of predominantly elderly people. EHOs also inspected homes and facilities for mold and recommended methods for abatement. Other activities included contacting daycare centers and mobile home parks to determine their environmental health status, and to provide technical assistance to address hazards such as leaking roofs with potential for mold growth, physical hazards such as fallen trees, other hazards such as damaged

perimeter fences and playground equipment, downed electrical lines and standing water serving as mosquito brreviewed public information handout titled “After the Stofluent in Spanish assisted a State Health Department admof environmental health questions in Spanish and assistedHispanic residents with limited English proficiency in Escofficers were asked to assist in preliminary investigation oof a resident. In a separate incident, a residential mercuryprovided technical information on exposure levels, healthrecommendations.

s

Many of the officers also participated in inspections of swcontrol purposes. During hurricanes, large amounts of deThis debris frequently caused the pool pumps to become cresulting in a mosquito breeding habitat.

OfficontwithHeaindivincremosafterFranmeaspecpestresidinvequan

LCDR Hroch assists in relocating sentinel chicken population used to monitor West Nile Virus

LCDR Kates taking water sample

eeding habitat. Officers rm”. In one situation, an EHO inistrator develop a printed list in communicating with ambia County. In another case, f a possible chemical exposure spill occurred, and EHOs effects and clean-up

imming pools for mosquito bris was blown into the pools. logged and non-functional,

cer's participated in a mosquito rol and pesticide exposure study the Florida Department of lth and the CDC to investigate if idual urinary pesticide levels ased during large-scale aerial

quito control efforts in Florida Hurricane Jeanne, Ivan, ces and Charlie. The study sured levels of metabolites ific to the mosquito control icides in urine collected from ents in the areas sprayed. This stigation will aid efforts to tify exposure of Florida

11

residents to aerial spraying of mosquito control pesticides resulting from such large-scale vector control efforts in response to hurricane disasters. To determine excess exposure to pesticides from increased mosquito control efforts, officers were teamed up with epidemiologists and physicians from CDC and the Florida Department of Health. Specifically the investigation was described to each potential participant. A pre-spray questionnaire was administered, and a pre-spray urine sample was collected. After the spraying episode, officer's re-visited all participants in the study to collect 4 post urine samples and administer a post-questionnaire. The pesticide used in the aerial spraying was DiBrom. The 4 officer's assigned to this project visited a total of 24 census areas consisting of over 500 homes. Officer's explained the scope of the study to residents and administered over 80 pre-study questionnaires and collected approximately 320 pre-spray urine samples. Tasks performed by the EHO's in support of county offices included:

• Development and review of post-storm public information handouts; • Water sampling of drinking water wells and permit inspections; • Comprehensive school surveys; • Hospital infectious waste disposal surveys; • Relocate a West Nile Virus sentinel chicken population used for disease

monitoring. • Nursing home surveys; • Daycare center surveys; • Responding to incidents of raw sewage outflow from lift stations without power; • Trailer park water/wastewater system surveys; • Food service establishment and mobile food service operation surveys; • Food service surveys for Florida Institute of Technology • Asbestos air sampling in shelter with damaged asbestos containing material; • Food service surveys of American Red Cross and other volunteer organization

food preparation centers; • Inspection of general population shelters; • West Nile surveillance and vector control; • Disaster response plan review; • Inspection of chlorine storage yards; • Mold inspections and recommendations for remediation at schools and other

public buildings; • Petroleum and propane tank inspections.

Successes:

1. Smooth transition between leadership by having at least one day of overlap;

2. Actively worked to maintain relationship with State Environmental Health offices;

3. We were able to quickly deploy officers to meet the needs in the counties;

12

4. Officers were very flexible in regards to filling the counties environmental health needs.

5. Officer's general environmental health expertise enabled them to effectively complete assigned tasks and work independently and in teams. This enabled the State Offices to focus on other issues of concern.

6. Officers able to deploy to assigned county very quickly and work effectively with travel coordinators;

7. Paired officers with varying levels of experience for deployment to the counties;

8. EHO's worked well within the command structure; 9. Assignment of lead officer for the county teams allowed for better

coordination with County Environmental Health Director; 10. Establishing a phone tree to contact officers in case of emergency, and

maintainiing contact with officers through daily calls; 11. Ability to reassign EH officers to areas where they were needed most.

Opportunities for Improvement: 1. Preplan for providing EHO support to Eenvironmental Health

Programs in affected counties and not just for shelter operations. 2. Identify expertise of EHO personnel with broad environmental health

experience prior to arrival. We needed EHO's with a general background in water, wastewater, and food issues.

3. Identify EHO's with specific certifications (i.e., REHS, CIH, CSP, etc.). In some situations, county environmental health administrators desired EHO's with these certifications.

4. Have DHHS agencies work within the framework of the OFRD mission when deploying officers.

5. If possible, establish email links so field EHO's can report to the EHO commander on their daily activities (possibly laptop computers, blackberry, or PDA with email and internet capability).

6. Need for a pre-assignment briefing/meeting with incoming officers upon arrival to hotel to clarify assignments.

7. As we discovered during the mission, the counties had a need for EHOs in the field and not just for special needs shelter operations.

8. Find hotel or lodging closer to assigned areas. This was difficult due to the hurricane disaster situation.

9. Increase flexibility of travel arrangements so officers can reduce travel time in order to maximize field work.

10. Need for cell phones for all officers to stay in communication as new storm approached and for daily reporting from field EHO's on their activities.

11. Need for EH equipment field kits to be assigned to deployed officers. 12. EHOPAC Emergency Response Subcommittee should consider

maintaining information "fact sheets" on various EH hazards common to hurricanes, floods, or other disasters for health departments to use.

13

Additional Photographs

14

General storm damage

15

General Storm Damage.

16

Public Shelter and Water distribution Center

17

Temporary food establishments and portable handwashing station.

18

Special needs shelters.

Electrical hazard from downed power lines. Extensive power outages.

19

Mobile home park inspections.

Surface sewage contamination

20

Flooding in convenient store. Boil water orders affect soda fountains.

Water main project

21

Inspection of mobile food facilities.

22

Electrical hazard from downed power lines

Mold growth on interior walls.

23

Mold growth on interior walls and ceilings.

Dehumidifiers to reduce relative humidity.

24