Community Risk Reduction for the Fire and Emergency Services

Applying the Haddon Matrix: Windows of Opportunity Applying the Haddon Matrix Windows of Opportunity Factors Risk_______ Host/Human Agent/Vehicle Environment Physical Pre-Event Phase Event Phase Post-event Phase FSC 3110, Community Risk Reduction for Fire and Emergency Services Socioeconomic/ Cultural Applying the Haddon Matrix: Windows of Opportunity Applying the Haddon Matrix Windows of Opportunity Factors Risk_______ Host/Human Agent/Vehicle Environment Physical Pre-Event Phase Event Phase Post-event Phase FSC 3110, Community Risk Reduction for Fire and Emergency Services Socioeconomic/ Cultural Research | Article The Application of the Haddon Matrix to Public Health Readiness and Response Planning Daniel J. Barnett, Ran D. Balicer, David Blodgett, Ayanna L. Fews, Cindy L. Parker, and Jonathan M. Links Johns Hopkins Center for Public Health Preparedness, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA State and local health departments continue to face unprecedented challenges in preparing for, recognizing, and responding to threats to the public’s health. The attacks of 11 September 2001 and the ensuing anthrax mailings of 2001 highlighted the public health readiness and response hurdles posed by intentionally caused injury and illness. Community Risk Reduction for the Fire and Emergency Services

At the same time, recent natural disasters have highlighted the need for comparable public health readiness and response capabilities. Public health readiness and response activities can be conceptualized similarly for intentional attacks, natural disasters, and human-caused accidents. Consistent with this view, the federal government has adopted the all-hazards response model as its fundamental paradigm. Adoption of this paradigm provides powerful improvements in efficiency and efficacy, because it reduces the need to create a complex family of situation-specific preparedness and response activities. However, in practice, public health preparedness requires additional models and tools to provide a framework to better understand and prioritize emergency readiness and response needs, as well as to facilitate solutions; this is particularly true at the local health department level. Here, we propose to extend the use of the Haddon matrix—a conceptual model used for more than two decades in injury prevention and response strategies—for this purpose. Key words: dirty bombs, emergency, Haddon matrix, injury prevention, preparedness, public health, readiness, response, SARS, terrorism. Environ Health Perspect 113:561–566 (2005). doi:10.1289/ehp.7491 available via http://dx.doi.org/ [Online 2 February 2005] Hypothetical Cases SARS Preparedness and Response It was an unseasonably warm Friday morning on 12 March 2004 in Anytown, Maryland. Since 1 March 2004, the Department of Homeland Security had raised the U.S. terror alert level to code orange (high) based on fresh intelligence reports from interviews with Al Qaeda detainees at Guantanamo Bay. Community Risk Reduction for the Fire and Emergency Services

The Baltimore Orioles were in the process of gearing up for another season. On Monday, 8 March 2004, 75 diehard baseball fans returned to Dulles Airport on Orioles Airways Flight 000, after watching the Orioles play a series of spring training exhibition games in Florida over the weekend. One of the passengers on this Orioles Airways Flight 000 was Mr. Smith, an Anytown, Maryland, businessman who had traveled to Taipei, Taiwan, for meetings during the week of 1 March 2004. He had taken a direct flight to Taipei from Dulles Airport on Monday, 1 March, with a stopover that day in Munich, Germany; he had flown back to Dulles on Thursday, 4 March, also with a stopover in Munich. Community Risk Reduction for the Fire and Emergency Services

Upon returning to Dulles, he spent the night at a hotel in McLean, Virginia. He flew the next morning, 5 March, from Dulles to Fort Lauderdale, Florida, on Orioles Airways Flight 007 to watch his beloved Orioles play a weekend’s worth of spring training games, before returning to Dulles on the 8 March Orioles Airways Flight 000. Early on the morning of 8 March, before boarding Flight 000, Mr. Smith developed a Environmental Health Perspectives sudden fever and dry cough, along with chills and muscle aches. Despite these symptoms, after the flight he still managed to drive from Dulles Airport to Anytown, Maryland. Within 2 hr of arriving at his apartment to his wife and two children in Anytown, Mr. Smith’s condition rapidly deteriorated, and he began to have difficulty breathing. His wife drove him to General Hospital emergency department in Anytown. Mr. Smith was admitted to the intensive care unit at General Hospital on 8 March, with a suspected clinical diagnosis of severe acute respiratory syndrome (SARS). Three days later (11 March), doctors at one hospital in Washington, DC, one hospital in Baltimore, and General Hospital in Anytown admitted three patients each (total = 9 patients) with histories of acute onset of high fever (> 38°C) and dry cough followed by shortness of breath. Upon taking a detailed travel history of these patients, physicians determined that seven of these nine patients (including the three new patients presenting to General Hospital in Anytown) had taken Orioles Airways Flight 000 on 8 March 2004. Two others had recently traveled to the United States from Guangdong Province, China. These developments were reported on a 24-hr cable media outlet before local, state, and federal public health officials had a chance to generate a formal press release. Meanwhile, at General Hospital in Anytown, the condition of Mr. Smith steadily worsened despite aggressive treatment efforts, • VOLUME 113 | NUMBER 5 | May 2005 and he died of respiratory failure on the afternoon of 11 March. By 2000 hr on 11 March, local, national, and international media outlets had converged upon Anytown, with a sea of television trucks and satellite equipment gathered outside General Hospital. Community Risk Reduction for the Fire and Emergency Services

The 911 system became flooded with calls from anxious citizens throughout Anywhere County, and cell phone networks were quickly overwhelmed by call volume. The mayor of Anytown, Maryland, and the local county health commissioner prepared to deliver a joint press conference with the state health commissioner at 2030 hr, followed by an address by the president to the nation on these developments at 2100 hr. By 13 March 2004, a total of 90 cases of SARS were confirmed in Maryland, Pennsylvania, northern Virginia, and the District of Columbia. Twenty of these patients had died thus far from respiratory failure. The news of these deaths brought added fear to the region and the nation. Schools had been closed and unnecessary gatherings canceled in Anytown and the rest of the affected region for the past 2 days. Epidemiologic workup by the Centers for Disease Control and Prevention (CDC) in conjunction with state and local health departments revealed that most cases in this SARS outbreak were traceable to Mr. Smith, the Anytown businessman who had been exposed to SARS while on business in Taipei and who subsequently exposed fellow passengers on Orioles Airways Flight 000 because of a faulty on-plane ventilation system. The remaining cases were traced to the two travelers to Baltimore who came from Guangdong Province in China. Questions. What are the hospital infection control issues associated with a SARS outbreak, and what are the most effective approaches to address these issues? What type Address correspondence to D. Barnett, Johns Hopkins Center for Public Health Preparedness, 615 N. Wolfe St., Room WB030, Baltimore, MD 21205 USA. Telephone: (410) 502-0591. Fax: (443) 287-7075. E-mail: dbarnett@jhsph.edu The development of this manuscript by Johns Hopkins Center for Public Health Preparedness was supported in part through a cooperative agreement U90/CCU324236-01 with the Centers for Disease Control and Prevention.

The authors declare they have no competing financial interests. Received 16 August 2004; accepted 2 February 2005. 561 Article | Barnett et al. of advance planning strategy could a local public health department use to identify the contributing factors to this public health emergency? What approaches could a local public health department use to deliver comprehensive public health prevention, intervention, and risk communication measures before, during, and after such an outbreak? “Dirty Bomb” Preparedness and Response It was late in the afternoon on a typically warm, humid, sunny 4 July afternoon in Anytown, Maryland. Thousands were gathered at the Anywhere County fairgrounds in Anytown in preparation for that evening’s upcoming parade and celebration, and the crowds were currently enjoying an outdoor concert and other festivities. Police estimated the afternoon’s crowd at the fairgrounds at approximately 10,000. Community Risk Reduction for the Fire and Emergency Services

There was a breeze blowing westward at 10 miles/hr, cooling the fairground crowd slightly and making them a little more comfortable. Tens of thousands more were en route to Anytown for the evening’s celebration via the major highways, including I-95, I-495, and I-270. There was heavy freeway congestion at this hour outside downtown Anytown. Warnings from the Department of Homeland Security had been issued for vigilance during the 4 July holiday weekend, but the nature of this terrorist threat had been nonspecific, and the nation had been at a U.S. terror alert level of code yellow on this 4 July holiday. It was estimated that 7,500 of the 10,000 people at the fairgrounds this afternoon were attending the concert. About 30 min into the show, a man driving a white van on Any Parkway suddenly stopped at the main entrance to the fairgrounds, about 50 yd from the concert venue. Ten seconds later the van exploded in a massive fireball, the blast hurling fiery shrapnel into the crowd. The explosion killed 300 people instantly and injured 2,000 more in the adjacent crowd, and the blast could be heard over a 5-mile radius. Smoke emanating from the resulting fire was visible to motorists on the congested freeways and roads leading to the fairgrounds. Within moments of the blast, thousands of people began fleeing from the fairgrounds. Motorists hearing the blast and seeing the smoke from area freeways and roads began to use their cell phones simultaneously by the thousands. Cellular phone systems rapidly became flooded. On Monday, 8 July, an Associated Press wire bulletin surfaced that three moisture density gauges—each containing 10 mCi  cesium-137—were first reported missing that morning from a construction site on Maryland’s Eastern Shore. Community Risk Reduction for the Fire and Emergency Services

The site manager said the gauges were last seen on 1 July, the day before the construction crew left the site for the extended holiday weekend. Given this new information, public safety authorities had a high index of suspicion that this terrorist blast may have been caused by a “dirty bomb” containing the cesium-137 from the Eastern Shore construction site. Environmental sampling revealed elevated radiation levels at the site of the explosion, consistent with this hypothesis. In the several weeks after the attacks, emergency rooms noted a surge in patients coming in for anxiety-related symptoms. Area pharmacies were flooded with prescriptions for anxiolytic and antidepressant medications. Community mental health services were being strained as Anytown citizens attempted to come to grips with the horror of this terrorist attack.

Many residents of Anytown stated they would never return to the city again because they believed the area would never be adequately decontaminated. Questions. What are the potential environmental impacts of a dirty bomb? What can be done to prepare for and respond to such impacts? How would local, state, and federal public health and partner emergency response agencies work together in this scenario? What steps would be taken to distinguish a dirty bomb vs. from another type of explosion? What steps would be taken to evacuate, contain, and decontaminate the affected area? Would evacuation involve all of Anywhere County? Who would take the lead in communicating timely, accurate information to the public on radiation terror before, during, and after this event? What would the crisis- and consequence-phase mental health service responses be to an attack on Anytown by a “dirty bomb”? What steps, if any, could have prevented this attack from occurring or could have reduced the number of deaths and injuries? Discussion The Haddon matrix. The field of injury prevention has long provided solution-oriented models for understanding threats to the public’s health. Industry and public health officials alike have applied these models to reduce morbidity and mortality from a variety of injury types. The Haddon matrix, developed by William Haddon, has been used for more than two decades in injury prevention research and intervention. The Haddon matrix is a grid with four columns and three rows. The rows represent different phases of an injury (preevent, event, and postevent), and the columns represent different influencing factors (host, agent/vehicle, physical environment, social Table 1.

The Haddon matrix and pedestrian injury from automobiles. Phase Preevent Event Host Physical environment Intoxicated driver Fatigued driver Speeding automobile Worn tires Poor street lighting Slick pavement Pedestrian crossing street Worn brakes Potholes Inadequate signage Nighttime Intoxicated pedestrian Elderly pedestrian Pedestrian with osteoporosis Pedestrian wearing headphones Hearing-impaired pedestrian Postevent Influencing factors Agent/vehicle Part of pedestrian’s body struck by vehicle Ability of victim to recover Postinjury care received Social environment Unenforced speed limit laws Inadequate investment in crosswalks Momentum of automobile Hospitals nearby with specialty in trauma care Impact of automobile with pedestrian Portion of vehicle impacting pedestrian Severity of physical injuries Good samaritan laws Part of body impacting ground Rehabilitation facility Health insurance Severity of postevent psychological impact Access to rehabilitation services Family and social support Psychological coping of victim in aftermath of event 562 VOLUME 113 | NUMBER 5 | May 2005 • Environmental Health Perspectives Article environment). Table 1 illustrates a basic application of the Haddon matrix to pedestrian traffic safety. The host column represents the person or persons at risk of injury. The agent of injury impacts the host through a vehicle (inanimate object) or vector (person or other animal/organism). Community Risk Reduction for the Fire and Emergency Services

Physical environment refers to the actual setting where the injury occurs. Sociocultural and legal norms of a community constitute the social environment. The phases of an event are depicted on the matrix as a continuum beginning before the event (preevent), the event itself (event phase), and sequelae of the event (postevent phase). | Haddon matrix and public health response planning The terminology used for the factors of the matrix can be adapted for different contexts; for example, “agent” may be more appropriate than “vector” in certain cases, and “organizational culture” might be used in addition to or instead of “social environment” (Tables 2–4) when focusing on an institutional context. Community Risk Reduction for the Fire and Emergency Services

Through its phase-factor approach, the Haddon matrix meshes concepts of primary, secondary, and tertiary prevention with the concept of the host/agent/environmental interface as a target for delivering public health interventions (Runyan 1998). Each cell of the matrix represents a distinct locus for identifying strategies to prevent, respond to, or mitigate injuries or other public health challenges (Runyan 1998). By dissecting a problem into its dimensions of time and contributing factors, the Haddon matrix can be applied as a practical, user-friendly interdisciplinary brainstorming and planning tool to help understand, prepare for, and respond to a broad range of public health emergencies (Runyan 2003). The Haddon matrix and new readiness challenges for public health. As an integral component of homeland security in the post–11 September environment, the public health infrastructure faces new and significant challenges of recognizing and responding to Table 2. The Haddon matrix and public health emergency readiness and response—a conceptual overview. Phase Preevent Host Agent/vector Risk assessment Properties of biologic, chemical radiologic, or other agents Capacity of agent as WMD Preevent risk communication Preevent surveillance Primary prevention (e.g., preevent vaccination) Preparedness training for public health responders Interagency first response planning Event Postevent Crisis risk communication Decontamination and treatment Sheltering Influencing factors Physical environment Existing clinical infrastructure Vulnerability of food and water supplies

Transportation infrastructure Potential for re-engineering of agent to produce unexpected health effects Proximity of community to chemical and radiation facilities Disease or injury caused by agent Response of the agent to decontamination and treatment efforts Potential for agent detection Postexposure Psychosocial impact of agent during prophylaxis event Crisis-phase mental Acute health effects of agent health response Crisis-phase interagency first response collaboration Epidemiological workup (including forensic epidemiology as applicable) Evacuation Consequence-phase Long-term psychosocial impact of agent risk communication Application of lessons Response of agent to mitigation and learned to improve cleanup efforts response systems Consequence-phase mental health response Postevent health surveillance Mitigation and cleanup After action assessment and follow-up Emergency response clinic setup and operations Emergency access to medical supplies (e.g., Strategic National Stockpile) Clinical surge capacity Shelter availability Social environment/organizational culture Need for culture of readiness among public health and other first responders Knowing one’s functional role(s) in emergency response* Demonstrating use of communication equipment* Knowing one’s communication role(s) in emergency response* Identifying key system resources for referring matters that exceed one’s personal knowledge and expertise* Participation in readiness exercises and drills Baseline community trust in public health and other response agencies Public acceptance of preevent risk communication Culturally based preevent risk perception Public awareness of large-scale threats Demographics of community Community responses to crisis risk communication Community adherence to public health guidance during event Culturally based crisis-phase risk perception Access of community to crisis response clinics Emergency accessibility of transportation Application of lessons learned to better safeguard vulnerable infrastructure Community responses to postevent risk communication Willingness of public health responders to embrace lessons learned Postevent community trust in public health and other response agencies Culturally based consequence-phase risk perception WMD, weapons of mass destruction.

*Potential targets for public health intervention. Environmental Health Perspectives • VOLUME 113 | NUMBER 5 | May 2005 563 Article | Barnett et al. a broad range of intentional and naturally occurring large-scale threats. Furthermore, since the anthrax attacks of 2001, the concept of public health emergency preparedness in the United States has evolved and expanded from a bioterrorism focus to an all-hazards readiness and response model. The all-hazards approach means that the infrastructure and skill sets used to prepare for and respond to a bioterrorism event can also be applied to a wide spectrum of current and emerging natural and intentional threats to the public’s health, ranging from an infectious disease outbreak to a weather-related disas … Community Risk Reduction for the Fire and Emergency Services