Public Health Feature - September 2009
Tex Med . 2009;105(9):33-37.
By Crystal Conde
Adolfo Valadez, MD, MPH, has not served even two years as assistant commissioner for Prevention and Preparedness Services at the Texas Department of State Health Services (DSHS), but he's already been involved in his fair share of natural disasters and public health emergencies. He was instrumental in leading the state's preparation for and response to Hurricane Ike last year, and he has overseen diagnostic testing of H1N1 specimens in the DSHS lab this year.
Before joining DSHS in January 2008, Dr. Valadez was the medical director and health authority for the Austin/Travis County Health and Human Services Department. During his time with the city, he led efforts to provide medical care for evacuees of hurricanes Rita and Katrina, established a medical special needs shelter, and worked closely with the Travis County Medical Society to identify physicians to care for the evacuees.
"That whole experience gave me some valuable skills I could transfer to the state level," he said.
Dr. Valadez received his medical degree from The University of Texas Medical Branch in Galveston (UTMB) and his master of public health degree from the Harvard School of Public Health.
In this interview with Texas Medicine , Dr. Valadez discusses how the state prepares for responding to natural disasters, lessons the department has learned from past hurricane responses, ongoing disaster response challenges and plans to address them, the physician's role in preparing for and responding to a natural disaster, and plans for responding to H1N1 swine flu.
Texas Medicine: How does the state prepare to respond to a hurricane?
Dr. Valadez: Hurricanes are the most predictable natural disaster, and they affect many people. A lot of effort goes into preparing for them.
DSHS works closely with the Governor's Division of Emergency Management in the Texas Department of Public Safety and with local public health departments to build preparedness capacity in communities.
We work with local trauma systems and hospitals to prepare for the need to evacuate hospitals. During a hurricane, we have to identify individuals with medical special needs, evacuate them, and shelter them in a healthy environment, all while providing them with support from health care professionals.
When we responded to Hurricane Ike, we had years of preparation and experience working in our favor. We coordinated with UTMB staff and were able to evacuate more than 245 hospital beds and 54 neonatal patients within 12 hours. That takes a lot of practice and preparation.
During Hurricane Ike, we evacuated approximately 1.9 million people and set up 41 medical special needs shelters. We had no deaths as a result of medical evacuation. About 74 people died from storm-related events. Many of those deaths occurred after the storm during recovery efforts.
Fallen tree accidents, electrocution, and carbon monoxide poisoning from improper use of generators are all preventable and require more public education. We want to limit accidents and preventable events that occur after the storm. This is where local public health departments come in and can help educate residents about post-hurricane safety. (See " Local Public Health Departments Key to Disaster Response .")
Texas Medicine : What lessons have you learned from respondes to past hurricanes?
Dr. Valadez: In collaborating with our partners, including the Texas Medical Association, we're focusing more on developing our own medical capacity. DSHS is a large agency, but not a lot of physicians, nurses, and other medical professionals work for us in a clinical role. They mostly take on leadership positions.
Oftentimes in responding to hurricanes, we need to contract with staffing agencies to ensure we can provide the needed health care. In addition, we rely on partners such as TMA to help us identify physicians who can provide care when residents need it most.
We've learned in our response to hurricanes that medical volunteers are helpful, but it can be a challenge to get them where they're needed if they have to move across the state.
We've also learned we need to create our own medical teams. We've developed 10 teams that consist of a physician and midlevel medical support staff, and we're planning to put them in the field during a response effort to provide medical care.
We've connected with some of our medical schools, including The University of Texas Southwestern Medical School and Texas A&M Health Science Center, to identify the team members. Now we're training them.
And we've learned that within our agency we have to be organized and develop teams with the appropriate mix of people who can effectively respond to public health emergencies and disasters. We run many response drills and practice for adverse events as if they're really happening.
Texas Medicine : What challenges does the state face in preparing to respond to a mass disaster or emergency, and how is DSHS addressing those?
Dr. Valadez: During Hurricane Ike, it became obvious to us that we have a large portion of individuals in home health settings. These are very sick people, many of whom have feeding tubes or ventilators. Some of them are morbidly obese bariatric patients.
With homebound patients, we face limitations in how we can transport and shelter them. We knew about these patients, but during Hurricane Ike, we realized we'd underestimated the sheer number of these patients and the magnitude of their medical needs.
In preparation for future responses, we are going to work with the local public health departments and within the communities to set up medical special needs shelters for these at-risk medical evacuees.
Another challenge we face is dealing with human nature and the coping mechanism of denial. People may not want to evacuate, and we have to work to change those behaviors.
If some people say they can't evacuate because they don't have a vehicle, we provide transportation. We also educate people on the importance of evacuating.
One of the challenges the department has faced is identifying resources such as staff, equipment, and funding necessary for an effective response. The 81st Texas Legislature appropriated approximately $7.3 million to DSHS for disaster response. Legislators also enacted legislation that supports emergency and disaster management. (See " Emergency Management Legislation .")
Texas Medicine : What is the physician's role in preparing for and responding to a natural disaster?
Dr. Valadez: Physicians can play a role in planning because they know what needs to be done from a clinician's perspective. Clinicians in areas where hurricanes typically strike can help make sure patients and families have a plan for evacuation, contact information for their physicians, prescription information, and an accurate medical history.
In these emergency situations, clinicians play an important consultative role by working with local communities and health departments in managing many chronic medical conditions.
Physicians also play a part in responding. Many opportunities exist for physicians of all specialties and backgrounds to respond. We need psychiatrists and mental health professionals, internists, obstetrician-gynecologists, family physicians, pediatricians, physicians qualified in treating chemical dependency, and emergency medicine physicians. Doctors who want to help in times of disaster can also reach out to their local public health departments, TMA, and their county medical societies. (Physicians who wish to be contacted to volunteer during public health emergencies may sign up on TMA's Disaster Preparedness Resource Center online.) Physicians also should think about continuity of operations. Physicians living in and near hurricane-impact areas should have plans in place to continue to see patients. They should have a way to deliver critical medical services to people during a natural disaster.
Texas Medicine : Physicians likely will contend with H1N1 flu at the same time as seasonal flu. What is DSHS doing to prepare physicians and local health departments to ensure they respond appropriately and effectively?
Dr. Valadez: DSHS is the lead agency for Texas' response to H1N1. This was a completely novel virus never before seen in North America, and because of that, DSHS called for specimens. Our lab received more than 10,000 specimens, more than we get in an entire flu season.
We were able to increase surge capacity in our lab tenfold. Our lab isn't diagnostic, but we learned we'll have to resort to using it for that purpose.
We know what the virus is now, so we have a better idea of what to expect in the fall. We can plan better. In responding to both H1N1 flu and seasonal flu, we will let local communities know our plan for antiviral distribution and our plan for H1N1 vaccine distribution and allocation if a vaccine is available. We're still working with CDC (Centers for Disease Control and Prevention) to implement that plan.
We'll also send out messages about the importance of community mitigation via hand washing, social distancing, canceling public events, and other practices.
The message to physicians is to ensure health care workers receive immunizations against seasonal flu. Only about 43 percent of health care workers get a flu vaccine.
Vaccinating high-risk patients, such as the elderly, pregnant women, infants, and those with chronic health conditions is especially important. Physicians need to review their patients' immunization histories and ensure their vaccinations are up to date.
Physicians also need to have a plan in place if staff members get the flu so they can continue to provide services. They should examine what they've done in their practices to prevent the spread of flu among patients and staff. Those plans are critical, and physicians need to work with their local health departments to ensure they have those plans in place.
Even a moderately severe flu season combined with H1N1 will tax doctors' offices. They need to remind people to practice hand washing, cough covering, and staying home when they're sick.
To stay on top of the potential severity of a swine flu reemergence and to be prepared for influenza season, physicians may visit the DSHS Web site, www.texasflu.org.
CDC has a seasonal influenza Web site for health professionals and a site dedicated to novel H1N1 influenza resources for clinicians .
TMA also set up an online Swine Flu Resource Center , www.texmed.org/swineflu, with the latest news, relevant articles, information for physicians, lab testing protocol, reports from the governor, and resources.
Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by-email at Crystal Conde .
Local Public Health Departments Key to Disaster Response
When Hurricane Ike made landfall in Galveston on Sept. 13, 2008, it disrupted the city's public health and medical infrastructure, caused numerous accidents and illnesses, and claimed more than 20 lives in Galveston County alone. Mark Guidry, MD, MPH, health authority for Galveston County & Cities and chief executive officer of Galveston County Health District (GCHD), oversaw the public health and medical response in Galveston County.
"The Galveston County Health District plays the lead role in coordinating a rapid response to health concerns after any disaster in Galveston County and cities. Since we were directly affected by the hurricane, we appreciated the extensive support the Texas Department of State Health Services [DSHS] gave to the health district and our communities in the aftermath of Hurricane Ike," Dr. Guidry said.
GCHD employees worked on many fronts - coordinating ambulance services; overseeing environmental inspections of food, water, septic, and sanitation systems; providing vaccinations to more than 15,000 residents and first responders; working with partners to rescue and shelter animals; actively surveying hurricane-related injuries and diseases; and providing medical support to individuals at a Galveston Island shelter.
According to Dr. Guidry, one of the challenges the health district faced was the breakdown of traditional sources of public information, such as television and newspapers. To ensure residents received important public health information following the storm, the district established a phone bank and sent employees door to door to pass out fliers with information about drinking-water safety, vaccinations, food safety, rodent control, and prevention of electrical fires, carbon monoxide poisoning, and injuries.
The health district's federally qualified health centers met the primary health care needs of the area by providing medication refills, mental health care, assistance to displaced UTMB patients, treatment for injuries, and other health care services.
Dr. Guidry says a great deal of planning and coordination goes into an effective hurricane response. The Galveston County Emergency Response Coalition, made up of local members of law enforcement and medical and public health personnel, meets each month to discuss preparation for natural disasters. And, the health district works closely with the Galveston County Medical Society to reach out to physicians so they know how to help their patients prepare for a disaster.
In addition, GCHD is a depot for vaccine storage. In the event of a hurricane, physicians who must evacuate may bring their vaccine supply to the health department to be stored in a refrigerator with a backup generator.
For more information about GCHD's local public health response to Ike, click here .
For more information about Texas' public health departments and health service regions, click here .
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Emergency Management Legislation
Adolfo Valadez, MD, MPH, assistant commissioner for Prevention and Preparedness Services at the Texas Department of State Health Services (DSHS), says he's pleased the 2009 Texas Legislature invested in public health for disaster response. He says the first step in improving the state's response to medical needs during emergencies is the ability to maintain a lifetime immunization registry.
Senate Bill 346 by Sen. Jane Nelson (R-Lewisville) directs the Health and Human Services Commission to develop guidelines for informing the public that once individuals turn 18, they or their parents may consent in writing to have their immunization information remain in ImmTrac, the state immunization registry. Children who turn 18 will have one year to consent to allowing DSHS to maintain their immunization histories in the registry.
The next step, he says, allows Texas to share its residents' immunization data with other states when emergencies force Texas residents to evacuate. Senate Bill 347 by Senator Nelson contains those provisions and also lets DSHS receive immunization information from the health authority of another state if its residents relocate to Texas because of a disaster.
"We can share data and save money in the long run because we're not revaccinating people," Dr. Valadez said.
Ensuring that first responders have proper protection from contracting diseases during public health emergencies is also pivotal to effective disaster preparedness and response.
SB 1328 by Senator Nelson provides for a DSHS study of the vaccination needs of first responders and their families during a disaster such as a hurricane or flood. DSHS will assess the vaccination status of first responders and their immediate family members; examine workplace immunization policies and insurance coverage for first responders; and make recommendations on educating first responders and their immediate family members about available options to obtain immunization services, regardless of insurance coverage.
Dr. Valadez says SB 1328 is important because it will allow DSHS to determine first responders' immunization status and any barriers to immunization they face.
"Then we can target our intervention efforts to get them protected. We can get a better sense of the concerns and address them appropriately," he said.
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Ike, One Year Later: Lessons Learned
By Steven D. Brown, MD, Corresponding Author, on Behalf of the Harris County Medical Society Council of Hospital Chiefs of Staff
September 2009 Texas Medicine Contents
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