Public Health Risk Assessment Report for the Commonwealth of Pennsylvania

Transcription

1 Public Health Risk Assessment Report for the Commonwealth of Pennsylvania Report Prepared for the Pennsylvania Department of Health Prepared by: Center for Public Health Readiness & Communication Drexel University Dornsife School of Public Health June 22, 2016

2 Table of Contents Summary 3 Background and Methods 4 Overview of the Tool... 4 Impact of Hazards on At-Risk Populations... 5 Incorporating Preparedness into Risk Assessment... 5 Results 6 Public Health Risk Assessment for Pennsylvania... 6 Discussion and Recommendations 12 Recommendations References 17 Appendix A. Public Health Risk Assessment by Emergency Preparedness Region, Pennsylvania A-1 East Central Region... A-1 North Central Region... A-3 North East Region... A-5 North West Region... A-7 North West Central Region... A-9 Pennsylvania Region 13 South West Pennsylvania... A-11 South Central Region... A-13 South Central Mountain Region... A-15 South East Region... A-17 Appendix B. Description of Calculations in the PA Public Health Risk Assessment Tool B-19 Probability... B-19 Severity... B-19 Risk... B-21 At-Risk Populations... B-21 Adjusted Risk... B-22 Preparedness... B-22 Planning Priority... B-23 2

3 Summary The Center for Public Health Readiness at Drexel University Dornsife School of Public Health completed a public health risk assessment for the commonwealth of Pennsylvania using the Public Health Risk Assessment Tool (PHRAT). This assessment examined the health-specific impacts and levels of preparedness for twenty different hazards that were identified as major threats by public health and health care planners in the commonwealth, and had been identified as significant concerns by hazard and vulnerability analyses conducted by local and state emergency management agencies in Pennsylvania, including the Pennsylvania All-Hazard Mitigation Plan. Planning priorities were ranked using quantitative metrics to assess the impacts of hazards on human health, with a focus on the emergency operations and response activities of the health care and public health systems. This assessment of risk also incorporated the impact of hazards on at-risk populations, and the self-assessed status of related preparedness capabilities in public health agencies and in the state s healthcare systems. The analysis was completed between using the most current data available. The top five hazards identified as overall public health planning priorities for the state were Pandemic Coastal storm Flood Utility outage Local infectious disease outbreak The Public Health Preparedness Capabilities (PHEP) warranting significant attention for these hazards were Community Recovery, Community Preparedness, Responder Safety, and Non-Pharmaceutical Interventions. The Healthcare Preparedness or Hospital Preparedness Program (HPP) capabilities that appeared to be most important for Pennsylvania to enhance were Healthcare System Preparation and Healthcare System Recovery. At-risk populations identified as having significant planning requirements for the highest priority hazards included children, the elderly, and persons living below the poverty line. This determination reflects the relatively large size of these populations across the commonwealth, in addition to the unique challenges they face in disasters. This same tool was used in to complete a public health risk analysis in Pennsylvania, although the analysis was conducted at the level of the state s nine emergency task force regions, and no statewide composite was completed. However, the current statewide ranking of hazards by planning priority is very similar to the rank order of hazards for most regions of the state when this analysis was completed four years earlier. Weighted averages based on population size were used to create this composite analysis. Thus, the statewide planning priorities reflect those of the more densely populated regions of Pennsylvania. This list of public health planning priorities differs from the rank order of hazards in the 2013 Pennsylvania All-Hazard Mitigation Plan, reflecting the unique public health and health care challenges of these high priority threats. 3

4 Background and Methods Overview of the Tool The Public Health Risk Assessment Tool used for this analysis assesses the health-specific impacts of hazards and integrates the special planning requirements for at-risk populations along with hazardspecific preparedness capabilities to create planning priorities. Figure 1 illustrates an overview of the components of the Public Health Risk Assessment Tool and how they are combined to generate a Planning Priority Score for each hazard. Detailed descriptions of the scoring methods and calculations used in the PHRAT are provided in Appendix C. Figure 1. Pennsylvania Public Health Risk Assessment Overview To assess the public health risk resulting from a specific hazard, the tool measures the severity of its impact in five major domains, using quantitative metrics: Human health Healthcare services Inpatient healthcare infrastructure Community health Public health services Each metric is calculated by creating a ratio of the hazard-specific impact to the baseline number for the community during non-disaster times. An example would be the number of hospital beds needed during an incident compared to the average number of hospital beds typically available in the community. All of the data needed to assess severity of impact were collected for every county in Pennsylvania and subsequently compiled into 9 groupings based on the Pennsylvania emergency preparedness regions 4

5 (e.g., the regional task forces). For the statewide assessment, scores from each of the nine regions were compiled using weighted averages based on the population size of each region. Hazards selected for this health-focused analysis were those that had been identified as significant threats in hazard vulnerability assessments (HVAs) previously conducted by local and state emergency management agencies in Pennsylvania, including the Pennsylvania All-Hazard Mitigation Plan. The hazards were also identified as major concerns by public health planners. Impact of Hazards on At-Risk Populations The PHRAT introduces the concept of adjusted risk, which weighs the risk of a hazard based on the additional planning necessary to ensure universal access to emergency response resources for at-risk populations. The Adjusted Risk Score thus reflects the overall health risk from a hazard in a jurisdiction (i.e., an assessment of its probability and anticipated impact on the health of a jurisdiction), viewed through the lens of the efforts required to minimize the consequences to vulnerable communities. The impact of a hazard on planning for at-risk populations was calculated by assessing the size of the population in a jurisdiction as well as the special planning considerations that are relevant for a specific hazard, in the areas of emergency communication and public information, sheltering and mass care, evacuation, and access to medical countermeasures. For this analysis, nine populations were considered: Persons with a hearing disability Persons with a vision disability Persons with an ambulatory disability Persons with a cognitive disability Persons with limited English proficiency Persons with income below the poverty level Persons with chronic diseases (diabetes was used as a proxy for chronic disease, as the condition increases susceptibility to many medical conditions and requires daily medication use) Children under 18 years Elderly persons, age 65 and older Data from the current U.S. Census (American Community Survey 2014) and the Centers for Disease Control and Prevention (Diabetes Data and Statistics) were used for this analysis. Incorporating Preparedness into Risk Assessment The tool generates a planning priority indicator for each hazard by comparing the ratio of the Adjusted Risk Score for each hazard with an assessment of the state s preparedness capabilities that are relevant for that hazard. Scores for the specific functions of both the Public Health Emergency Preparedness and Healthcare Preparedness Program capabilities were assigned subjectively by planners at the Pennsylvania Department of Health and reflect the Department s assessment of state-wide preparedness in both areas. These state-wide scores were used for this analysis. These indicators are then ranked, and the rank is referred to as the Planning Priority Score. The final assessment or score generated for each hazard is intended to assist planners with the prioritization of preparedness efforts. 5

6 Results Public Health Risk Assessment for Pennsylvania This public health risk assessment for Pennsylvania identified the following hazards as five highest ranking threats for public health emergency planning: 1. Pandemic 2. Coastal Storm 3. Flood 4. Utility Interruption 5. Local Infectious Disease Outbreak The at-risk populations identified as having significant planning requirements for these hazards include children, the elderly, and persons living below the poverty line. The large size of these populations across the state account for this concern, in addition to the unique challenges each faces during these types of emergencies. Table 1 lists the 20 hazards assessed in rank order by Planning Priority Score, which reflects the ratio of hazard-specific Adjusted Risk to Preparedness status. Table 1. Hazards in order of Planning Priority Score, Pennsylvania PPS* Hazard Planning Prioty 1 Pandemic CRITICAL 2 Coastal Storm CRITICAL 3 Flood CRITICAL 4 Utility Interruption CRITICAL 5 Localized Infectious Disease CRITICAL 6 Winter Storm HIGH 7 Hazardous Material Release HIGH 8 Tornado HIGH 9 Conventional Explosive HIGH 10 Nuclear Facility MODERATE 11 Biological Terrorism MODERATE 12 Civil Disturbance MODERATE 13 Radiation Dispersal Device MODERATE 14 Drought MODERATE 15 Active Shooter MODERATE 16 Temperature Extremes MODERATE 17 Chemical Terrorism LOW 18 Fire LOW 19 Earthquake LOW 20 Cyber Terrorism LOW *PPS = Planning Priority Score 1 Critical scores greater than 15.6 High scores between Moderate scores between Low scores below 7.8 6

7 Figure 2 illustrates the relationship between the Adjusted Risk Scores and the Preparedness Scores for each hazard for the state of Pennsylvania. The Adjusted Risk reflects the risk of a particular hazard (e.g., the product of the probability of a hazard occurring and the severity of its health impacts) adjusted by the planning needs of at-risk populations for that incident or hazard. The range of Preparedness Scores for all of the hazards is relatively narrow, ranging from 2.53 (drought) to 2.77 (civil disturbance), reflecting the very similar scores for the 15 PHEP capabilities and 8 HPP capabilities across the state, as assessed by the Bureau of Public Health Preparedness at the Pennsylvania Department of Health. The three hazards with the highest planning priority score (pandemic, costal storm, and flood) have essentially equivalent Preparedness Scores (within.03). These hazards have the highest Adjusted Risk Scores, thus, the final Planning Priority Score was impacted more by the high Adjusted Risk associated with the hazards than by the level of preparedness. Additionally, the Adjusted Risk Scores for pandemic, coastal storm, and flood were significantly higher than the other hazards, with scores of 84.93, 76.87, and respectively (the average Adjusted Risk Score for a hazard was 32.81). Figure 2. Hazards by Adjusted Risk v. Preparedness, Pennsylvania Preparedness Adjusted Risk 7

8 The Adjusted Risk Score is derived from the Risk Score (a product of probability and severity) and the At- Risk Populations Score. Figure 3 depicts the Risk scores for 20 hazards in Pennsylvania the probability and severity of each hazard without any adjustment for planning considerations related to high-risk communities. The hazards of the greatest concern have both a high probability and a high severity, and appear in the upper right quadrant of Figure 4. Pandemic, coastal storm, and utility interruption are in this quadrant. Pandemic has a high severity but lower probability relative to coastal storm. Conversely, coastal storm has a higher probability but a relatively low severity score. Flood, local infectious disease outbreak, winter storms, and fires are all among the highest probability incidents but have lower severity scores because their health-related impacts are more likely to be focused in local areas or regions, with less morbidity and mortality than a widespread event like a pandemic. Figure 3. Hazards by Risk (Probability v. Severity), Pennsylvania Severity Pandemic Bio Terrorism Nuclear Facility RDD Chem Terrorism Utility Interr HazMat Release Tornado Civil Disturbance Conv Explosive Active Shooter Cyber Terrorism Drought Temp Extreams Earthquake Probability Coastal Storm Flood Localized ID Winter Storm Fire 8

9 Table 2 displays the Risk scores and Adjusted Risk scores for each hazard, in descending order of Adjusted Risk. The degree to which the Adjusted Risk is greater than the Risk depends on the value of the At-Risk Populations Score, which reflects the magnitude of the planning considerations for at-risk communities who have special needs, as well as the size of those populations within the state as measured by percentage of the total population. A disease pandemic can have a disproportionate impact on individuals with special health care needs, requiring targeted plans for medical countermeasures in addition to specific plans for communication, hence the large Adjusted Risk associated with this hazard. Similarly, coastal storm, floods, and utility interruptions can disrupt power; require evacuation and also special emergency information and warning all of which require special considerations for at-risk individuals with special needs. Table 2. Risk and Adjusted Risk Scores for 20 Hazards, Pennsylvania 2016 Hazard Adjusted Risk Risk Pandemic Coastal Storm Flood Utility Interruption Localized Infectious Disease Winter Storm Hazardous Materials Release Tornado Conventional Explosive Nuclear Facility Biological Terrorism Civil Disturbance Radiation Dispersal Device Temperature Extremes Drought Active Shooter Chemical Terrorism Fire Earthquake Cyber Terrorism

10 Figure 4 depicts the At-Risk Populations Score for each of the 20 hazards analyzed using the tool. The hazards with the highest At-Risk Populations Scores are those with the highest number of unique planning considerations necessary for at-risk populations, and that require plans to be developed for atrisk populations in all four distinct planning areas of communication, evacuation, sheltering, and medical management. While the Figure depicts that terrorism events (e.g., radiation dispersal device, conventional explosives and chemical terrorism) have high At-Risk Populations Scores, overall, the variance for all 20 of these scores for all the hazards is small. Overall, the hazards with the highest initial risk (unadjusted for planning related to populations with special needs) remain the hazards with the highest adjusted risk. Figure 4. At-Risk Populations Scores by Hazard, Pennsylvania At-Risk Population Score Hazard The Preparedness Score is derived from the self-reported assessment of the jurisdiction s achievement of the either the CDC Public Health Emergency Preparedness (PHEP) Capabilities or the Hospital Preparedness Program (HPP) Capabilities (Capability Status Score), and the relevance of that capability to preparation and response for a specific hazard (Capability Relevance Score). Figures 5 and 6 illustrate the state s public health preparedness capability status and the assessed relevance of the capabilities for the top-three hazards, Pandemic and Coastal Storm/Flood, respectively (Coastal Storm and Flood were combined as they received identical scores). Based on the top-three hazards identified in this analysis, the most important PHEP capabilities for the state of Pennsylvania to enhance are Community Recovery, Community Preparedness, Responder Safety, and Non-Pharmaceutical Interventions. Figures 7 and 8 illustrate the state s healthcare preparedness capability status and the assessed relevance of the capabilities for the top-three hazards, Pandemic and Coastal Storm/Flood, respectively. The most critical HPP capabilities for Pennsylvania to enhance are Healthcare System Preparedness and Healthcare System Recovery. 10

11 Figure 5: Public Health Preparedness Capability Status v. Capability Relevance (Pandemic), Pennsylvania Capability Status Mass Care Emerg Ops Coord Med Materiel Mgmt PH Surv & Epi Info Sharing MCM Dispens Emerg Public Info PH Lab Testing Volunteer Mgmt Medical Surge Community Prep Responder Safety Non-Pharm Interv Community Recov Capability Relevance Figure 6: Public Health Preparedness Capability Status v. Capability Relevance (Coastal Storm/Flood) Pennsylvania Capability Status 3 2 MCM Dispens Non-Pharm Interv PH Lab Testing Emerg Public Info Emerg Ops Coord Med Materiel Mgmt Info Sharing PH Surv & Epi Mass Care Volunteer Mgmt Medical Surge Community Prep Responder Safety Community Recov Capability Relevance 11

12 Figure 7: Healthcare Preparedness Capability Status v. Capability Relevance (Pandemic), PA Info Sharing Capability Status 3 2 Volunteer Mgmt Medical Surge Emerg Ops Coord Responder Safety HC System Prep Fatality Mgmt 1 HC System Recov Capability Relevance Figure 8: Healthcare Preparedness Capability Status v. Capability Relevance (Coastal Storm/Flood), PA Info Sharing Capability Status 3 2 Fatality Mgmt Responder Safety Medical Surge Volunteer Mgmt Emerg Ops Coord HC System Prep 1 HC System Recov Capability Relevance to Hazard Summaries of the Planning Priorities, Risk, Adjusted Risk, and Preparedness Scores for the nine emergency preparedness task force regions in Pennsylvania are provided in Appendix A. 12

13 Discussion and Recommendations A total of 20 different types of hazards were analyzed for the Pennsylvania using the Drexel PHRAT. The hazards identified as top five planning priorities overall were: (1) Pandemic, (2) Coastal Storm, (3) Flood, (4) Utility Interruption, and (5) Localized Infectious Disease. The populations identified as having the most significant planning requirements for these hazards include children and individuals older than 65 years. The third most significant at-risk population for these hazards is individuals living in poverty. These three population groups will require the greatest extent of planning based on their relative population size, as each represent large percentages of the overall population (>15 %) in the commonwealth. Other at-risk populations, including those with special health care needs and special communication challenges, require careful and targeted planning for these hazards, but represent significantly smaller percentages of the population. Mapping these as well as other at-risk populations should assist public health planners, particularly those working at the local and regional level. Emergency preparedness plans should be informed by an understanding of the relative size of these populations as well as their specific needs during emergencies that threaten their health. The Public Health Emergency Preparedness capabilities that appeared to be most important for Pennsylvania to enhance for these incidents were, Community Recovery, Community Preparedness, Responder Safety, and Non-Pharmaceutical Interventions. The Healthcare Preparedness or Hospital Preparedness Program (HPP) capabilities that appeared to be most important for Pennsylvania to enhance were Healthcare System Preparedness and Healthcare System Recovery. The functions for community and health care preparedness, as well as community and health care recovery, require capacity for needs assessment, and capacity for broad coordination across systems that can support public health and health care needs, including medical/mental/behavioral health systems. Conversely, the functions related to Responder Safety and Non-Pharmacological Interventions require targeted training and investments in very specific response activities that must be tailored to specific hazards. The PHRAT analysis was conducted with a deliberate effort to limit changes to the tool in order to allow for a comparison with the results from The findings from this year remained largely consistent with the prior analysis. The top hazards in each region remained largely the same, with only minor shifts in hazards (changes of one or two positions in ranking). The most notable difference in this year s report relative to the 2013 report was that regional analyses were aggregated into a single state analysis, using averages weighted by population density. The primary difference between the analysis of the regional task forces and the aggregate state score is the shifting of hazards towards the results for the heavily populated eastern regions of Pennsylvania. Changes in planning priority or adjusted risk estimates in this tool require significant changes in either specific preparedness scores, or significant changes in health care or public health capacity relative to the anticipated impact or needs posed by a hazard. In this analysis, those metrics remained relatively constant compared to the 2013 assessment. The highest ranking hazards in this public health risk assessment for Pennsylvania differ from the highest ranking hazards in the Pennsylvania Emergency Management Agency s 2013 State Standard All Hazard Mitigation Plan. The tool used for the public health risk analysis focuses specifically on the health consequences of hazards and the demands those hazards place on the public health and health care systems in Pennsylvania. It also encompasses the additional planning required to address the needs of at-risk populations. The State All-Hazard Mitigation Plan relies on historical data, local knowledge and general consensus opinions collected from emergency managers and other planners. The risk 13

14 assessment factors include probability, impact, spatial extent, warning time, and duration. Thus, it is perhaps not surprising that hazards such as pandemic and local infectious disease outbreaks rank at number 1 and 5 respectively as the greatest public health hazards facing the commonwealth in this analysis. Pandemics rank high because of the significant impact across all 5 health-related domains in the PHRAT, despite their relatively low probability. Local infectious disease outbreaks have moderate health-related impacts but occur with relative frequency in a hundred year cycle. In the Pennsylvania 2013 All-Hazard Mitigation Plan, pandemic ranks 17; local infectious disease outbreak appears as number 25 ( mass food contamination ) among the 26 hazards analyzed. However, beyond these two biological hazards (disease hazards), the planning priority hazards of the PHRAT closely resemble the top hazards identified in the Pennsylvania All-Hazard Mitigation Plan. Four of the six highest ranking hazards are the same in each analysis. From this it can be concluded that these hazards have the potential to have a notable impact across sectors including the health sector. This includes hazards that are typically not considered for their impact on human health such as utility interruptions and winter storms. A comparison of the rank order of hazards from this PHRAT as well as the Pennsylvania All-Hazard Mitigation Plan is provided in Table 3. Table 3. Public Health Hazards in Rank Order, PHRAT vs. All-Hazard Mitigation Plan Hazard Public Health Risk Rank All-Hazards Plan Rank Pandemic 1 19 Coastal Storm 2 4 Flood 3 1 Utility Interruption 4 3 Localized Infectious Disease 5 25 Winter Storm 6 2 Hazmat Release 7 9 Tornado 8 14 Conventional Explosive 9 20* Nuclear Facility Accident 10 6 Biological Terrorism 11 20* Civil Disturbance Radiation Dispersal Device 13 20* Drought Active Shooter 15 N/A Temperature Extremes Chemical Terrorism Fire Earthquake Cyberterrorism 20 N/A *For the purposes of this comparison, these events are categorized as Terrorism in the All-Hazard Plan. N/A - does not appear specifically as a threat or hazard in the ranked results in the All-Hazard Plan. Specific hazards assessed in the All-Hazard Plan that were not analyzed in the PHRAT include: dam failure, transportation accident, coastal erosion, landslide, lightening strike, invasive species, radon exposure, hailstorm, levee failure, subsidence, sinkhole. 14

15 Recommendations The following recommendations can be made based on the findings of this public health risk assessment for Pennsylvania: 1. Preparedness and mitigation strategies designed to reduce the impact of the highest-ranked threats should utilize cross-cutting approaches that will also enhance preparedness for many different hazards. Investments in preparedness and mitigation strategies for the highest-ranked hazards should provide the region with significant preparedness capacity for a number of additional threats that have similar characteristics. Public health agency and healthcare planners in Pennsylvania should consider ways to develop preparedness and response strategies that would be applicable to the largest number of threats, and not only the highest-ranking hazards. For example, the greatest threats for public health systems in the region are pandemic and coastal storm. Strengthening capabilities in Community Recovery, Community Preparedness, Responder Safety, and Non-Pharmaceutical Interventions will improve the state s readiness for these and most of the other hazards that the commonwealth is likely to face. In addition, building capacity across all of the PHEP and HPP capabilities will be reflected in selfassessed preparedness scores, and ultimately in the planning priority scores that this tool generates, allowing comparisons over time to measure improvement and readiness for public health emergencies. 2. Significant planning efforts are needed for at-risk populations to ensure that emergency preparedness, response, and recovery strategies truly serve whole communities. This risk assessment provides the first steps to considering the impact on at-risk populations within communities, with respect to their size and specific needs in disasters. The at-risk populations that emerged as significant concerns across hazards children, the elderly and persons living below the poverty line represent over 15% of the population of the commonwealth. In many communities, children and the elderly comprise over 25% of the population, respectively. Preparedness and response strategies should leverage the assets and expertise of the community partners that serve these populations, and the populations themselves. The medical community, particularly community-based practitioners working in primary medical care, serves these at-risk populations on a daily basis and will play a critical role during public health emergencies and in the recovery from disasters. Additionally, agencies in the social service and human service sector are important partners with whom government agencies can work throughout the emergency management cycle to meet the needs of these populations. Pennsylvania planners and public health officials should make every attempt to include these partners in preparedness efforts in order to best serve the needs of at-risk populations in local communities. 3. Public health planners at the local and regional level should know where the highest-risk populations are in their communities, and how to address their needs. Targeted emergency planning remains critical for individuals with specific functional needs, including access and 15

16 mobility and communications challenges to ensure their safety during disasters. Emergencies are local and the response to them occurs locally. Data regarding the geographic location and population density of a large range of high-risk populations with functional needs are available from the United States Census American Community Survey, the Centers for Disease Control and Prevention Social Vulnerability Index, and the US Department of Health and Human Services empower map. Mapping populations with unique challenges in emergencies is an important component of public health emergency planning at the local and regional level, and should be considered in conjunction with the findings provided by this public health risk analysis. The Center for Public Health Readiness and Communication has developed maps for planners in Pennsylvania using data from these sources and can share these with planners who are developing medical countermeasure strategies as well as broader responses to other emergencies. 4. The findings of this public health risk assessment should be shared with stakeholders across the state, within regional emergency preparedness task forces and other local emergency planning committees and forums. Unlike many other risk assessment tools that rely on subjective assessments and opinions, this PHRAT is a quantitative instrument that uses data from recent disasters and current public health and health care system capacity to characterize risk based on hazard impact and vulnerability. However, the tool is not intended to replace the important process of community engagement and input into assessment of risk. The findings from this public health risk assessment should be shared with public safety and health partners across the state, and with affected communities. Community input is necessary to address the specific planning challenges that these hazards present, particularly for the highest-risk populations across the state and its emergency planning regions. 16

17 References Armstrong, J. H., & Frykberg, E. R. (2007). Lessons from the Response to the Virginia Tech Shootings. Disaster Medicine and Public Health Preparedness, 1, S7-S8. doi: Doi /Dmp.0b013e Aronson, S. S., Shope, T. R., & Cotler, J. (2008). Managing infectious diseases in child care and schools : a quick reference guide (2nd ed.). Elk Grove Village, IL: American Acadmey of Pediatrics. Baker Jr, M. (2011). Elk County 2011 Hazard Mitigation Plan. Philadelphia. Beatty, M. E., Phelps, S., Rohner, C., & Weisfuse, I. (2006). Blackout of 2003: Public health effects and emergency response. Public Health Reports, 121(1), CDC. (2005). Public Health Consequences from Hazardous Substances Acutely Released During Rail Transit --- South Carolina, 2005; Selected States, MMWR, 54(03), 4. Ciottone, G. R. (2006). Disaster medicine (1st ed.). Philadelphia, PA: Mosby Elsevier. Department of Homeland Security. (2006). National Planning Scenarios Version 21.3 (pp. 161). Dunning, A. E., & Oswalt, J. L. (2007). Train Wreck and Chlorine Spill in Graniteville, South Carolina: Transportation Effects and Lessons in Small-Town Capacity for No-Notice Evacuation. Transportation Research Record: Journal of the Transportation Research Board, 6. Earthsky. (2011, June 7). Massachusetts tornado left a track visible from space Retrieved June 8, 2012, from Evans, C. A. (1993). Public-Health Impact of the 1992 Los-Angeles Civil Unrest. Public Health Reports, 108(3), FEMA. (1997). Multi-Hazard Identification and Risk Assessment: A Cornerstone of the National Mitigation Strategy. Washington, D.C. FEMA. (2011). IS Active Shooter: What You Can Do. Independent Study Program Retrieved March 30, 2012, from Goozner, B., Lutwick, L. I., & Bourke, E. (2002). Chemical terrorism: a primer for [Historical Article]. J Assoc Acad Minor Phys, 13(1), GRTI. (2007). Chlorine's Casualties and Counsel: GTRI Scientists and Engineers Assist in Aftermath of Chlorine Spill Case Study Retrieved April 3, 2012, from Lawrence. ( 2004). Lawrence County Hazard Mitigation Plan. New Castle: Lawrence County, PA. Matson, J. (2012, March 6). 1 Year after Fukushima: Could It Happen in the U.S.?, Scientific American. Retrieved from National Weather Service Forecast Office (NWS). (n.d.). The Tornado Outbreak of May 31, In National Weather Service Forecast Office: Cleveland, Ohio. Retrieved March 7, 2013, from NOAA. (2010a, September 2). A Meteorological Diagnosis of the Chicago Killer Heat Event of July 13, 1995, from NOAA. (2010b). State of the Climate: National Snow & Ice for February 2010 Retrieved March 29, 2012, from PEMA. Pennsylvania 2013 Standard State All-Hazard Mitigatio Plan. Retrieved June 3, 2016 from Assistance/Documents/General%20Mitigation%20Forms%20and%20Information/Pennsylvania %20State%20Hazard%20Mitigation%20Plan%20-%20Oct%2031% pdf Wheeler, C., Vogt, T. M., Armstrong, G. L., Vaughan, G., Weltman, A., Nainan, O. V.,... Bell, B. P. (2005). An outbreak of hepatitis A associated with green onions. New England Journal of Medicine, 353(9),

18 Appendix A. Public Health Risk Assessment by Emergency Preparedness Region, Pennsylvania East Central Region Table. Hazards in order of Planning Priority Score, East Central Region, Pennsylvania PPS* Hazard Planning Priority 1 Pandemic CRITICAL 2 Coastal Storm CRITICAL 3 Flood CRITICAL 4 Utility Interruption CRITICAL 5 Localized Infectious Disease CRITICAL 6 Winter Storm HIGH 7 Hazardous Material Release HIGH 8 Tornado HIGH 9 Conventional Explosive HIGH 10 Nuclear Facility MODERATE 11 Biological Terrorism MODERATE 12 Civil Disturbance MODERATE 13 Radiation Dispersal Device MODERATE 14 Active Shooter MODERATE 15 Drought MODERATE 16 Temperature Extremes MODERATE 17 Chemical Terrorism LOW 18 Fire LOW 19 Earthquake LOW 20 Cyber Terrorism LOW *PPS = Planning Priority Score 1 Critical scores greater than 15.6 High scores between Moderate scores between Low scores below 7.8 A-1

19 Figure 1. Hazards by Risk (Probability vs Severity) East Central Region, Pennsylvania Probability Severity 2.75 Figure 2. Hazards by Preparedness vs Adjusted Risk East Central Region, Pennsylvania Preparedness Adjusted Risk A-2

20 North Central Region Table. Hazards in order of Planning Priority Score, North Central Region, Pennsylvania PPS* Hazard Planning Priority 1 Pandemic CRITICAL 2 Coastal Storm CRITICAL 3 Flood CRITICAL 4 Utility Interruption CRITICAL 5 Localized Infectious Disease CRITICAL 6 Hazardous Material Release HIGH 7 Winter Storm HIGH 8 Tornado HIGH 9 Conventional Explosive HIGH 10 Biological Terrorism MODERATE 11 Civil Disturbance MODERATE 12 Active Shooter MODERATE 13 Radiation Dispersal Device MODERATE 14 Drought MODERATE 15 Temperature Extremes MODERATE 16 Nuclear Facility MODERATE 17 Chemical Terrorism LOW 18 Fire LOW 19 Earthquake LOW 20 Cyber Terrorism LOW *PPS = Planning Priority Score 1 Critical scores greater than 15.6 High scores between Moderate scores between Low scores below 7.8 A-3

21 Figure 1. Hazards by Risk (Probability vs Severity) North Central Region, Pennsylvania Probability Severity 2.80 Figure 2. Hazards by Preparedness vs Adjusted Risk North Central Region, Pennsylvania Preparedness Adjusted Risk A-4

22 North East Region Table. Hazards in order of Planning Priority Score, North East Region, Pennsylvania PPS* Hazard Planning Priority 1 Pandemic CRITICAL 2 Coastal Storm CRITICAL 3 Flood CRITICAL 4 Utility Interruption CRITICAL 5 Localized Infectious Disease CRITICAL 6 Winter Storm HIGH 7 Hazardous Material Release HIGH 8 Tornado HIGH 9 Conventional Explosive MODERATE 10 Biological Terrorism MODERATE 11 Civil Disturbance MODERATE 12 Radiation Dispersal Device MODERATE 13 Drought MODERATE 14 Nuclear Facility MODERATE 15 Active Shooter LOW 16 Temperature Extremes LOW 17 Chemical Terrorism LOW 18 Fire LOW 19 Earthquake LOW 20 Cyber Terrorism LOW *PPS = Planning Priority Score 1 Critical scores greater than 15.6 High scores between Moderate scores between Low scores below 7.8 A-5

23 Figure 1. Hazards by Risk (Probability vs Severity) North East Region, Pennsylvania Probability Severity 2.80 Figure 2. Hazards by Preparedness vs Adjusted Risk North East Region, Pennsylvania Preparedness Adjusted Risk A-6

24 North West Region Table. Hazards in order of Planning Priority Score, North West Region, Pennsylvania PPS* Hazard Planning Priority 1 Pandemic CRITICAL 2 Coastal Storm CRITICAL 3 Flood CRITICAL 4 Utility Interruption CRITICAL 5 Localized Infectious Disease CRITICAL 6 Winter Storm HIGH 7 Hazardous Material Release HIGH 8 Tornado HIGH 9 Conventional Explosive HIGH 10 Biological Terrorism MODERATE 11 Civil Disturbance MODERATE 12 Radiation Dispersal Device MODERATE 13 Active Shooter MODERATE 14 Drought MODERATE 15 Temperature Extremes MODERATE 16 Nuclear Facility MODERATE 17 Chemical Terrorism LOW 18 Fire LOW 19 Earthquake LOW 20 Cyber Terrorism LOW *PPS = Planning Priority Score 1 Critical scores greater than 15.6 High scores between Moderate scores between Low scores below 7.8 A-7

25 Figure 1. Hazards by Risk (Probability vs Severity) North West Region, Pennsylvania Probability Severity 2.80 Figure 2. Hazards by Preparedness vs Adjusted Risk North West Region, Pennsylvania Preparedness Adjusted Risk A-8

26 North West Central Region Table. Hazards in order of Planning Priority Score, North West Central Region, Pennsylvania PPS* Hazard Planning Priority 1 Pandemic CRITICAL 2 Coastal Storm CRITICAL 3 Flood CRITICAL 4 Utility Interruption CRITICAL 5 Localized Infectious Disease CRITICAL 6 Hazardous Material Release HIGH 7 Winter Storm HIGH 8 Tornado HIGH 9 Conventional Explosive HIGH 10 Biological Terrorism MODERATE 11 Civil Disturbance MODERATE 12 Active Shooter MODERATE 13 Radiation Dispersal Device MODERATE 14 Drought MODERATE 15 Temperature Extremes MODERATE 16 Chemical Terrorism LOW 17 Nuclear Facility LOW 18 Fire LOW 19 Earthquake LOW 20 Cyber Terrorism LOW *PPS = Planning Priority Score 1 Critical scores greater than 15.6 High scores between Moderate scores between Low scores below 7.8 A-9

27 Figure 1. Hazards by Risk (Probability vs Severity) North West Central Region, Pennsylvania Probability Severity 2.80 Figure 2. Hazards by Preparedness vs Adjusted Risk North West Central Region, Pennsylvania Preparedness Adjusted Risk A-10

28 Pennsylvania Region 13 South West Pennsylvania Table. Hazards in order of Planning Priority Score, Region 13 (South West), Pennsylvania PPS* Hazard Planning Priority 1 Pandemic CRITICAL 2 Coastal Storm CRITICAL 3 Flood CRITICAL 4 Utility Interruption CRITICAL 5 Localized Infectious Disease CRITICAL 6 Winter Storm HIGH 7 Hazardous Material Release HIGH 8 Tornado HIGH 9 Conventional Explosive HIGH 10 Nuclear Facility MODERATE 11 Biological Terrorism MODERATE 12 Radiation Dispersal Device MODERATE 13 Civil Disturbance MODERATE 14 Drought MODERATE 15 Temperature Extremes MODERATE 16 Active Shooter LOW 17 Chemical Terrorism LOW 18 Fire LOW 19 Earthquake LOW 20 Cyber Terrorism LOW *PPS = Planning Priority Score 1 Critical scores greater than 15.6 High scores between Moderate scores between Low scores below 7.8 A-11

29 Figure 1. Hazards by Risk (Probability vs Severity) Region 13, South West Pennsylvania Probability Severity 2.80 Figure 2. Hazards by Preparedness vs Adjusted Risk Region 13, South West Pennsylvania Preparedness Adjusted Risk A-12

30 South Central Region Table. Hazards in order of Planning Priority Score, South Central Region, Pennsylvania PPS* Hazard Planning Priority 1 Pandemic CRITICAL 2 Coastal Storm CRITICAL 3 Flood CRITICAL 4 Utility Interruption CRITICAL 5 Localized Infectious Disease CRITICAL 6 Winter Storm HIGH 7 Hazardous Material Release HIGH 8 Tornado HIGH 9 Nuclear Facility HIGH 10 Conventional Explosive HIGH 11 Biological Terrorism MODERATE 12 Civil Disturbance MODERATE 13 Radiation Dispersal Device MODERATE 14 Drought MODERATE 15 Temperature Extremes MODERATE 16 Active Shooter LOW 17 Chemical Terrorism LOW 18 Fire LOW 19 Earthquake LOW 20 Cyber Terrorism LOW *PPS = Planning Priority Score 1 Critical scores greater than 15.6 High scores between Moderate scores between Low scores below 7.8 A-13

31 Figure 1. Hazards by Risk (Probability vs Severity) South Central Region, Pennsylvania Probability Severity 2.80 Figure 2. Hazards by Preparedness vs Adjusted Risk South Central Region, Pennsylvania Preparedness Adjusted Risk A-14

32 South Central Mountain Region Table. Hazards in order of Planning Priority Score, South Central Mountain Region, Pennsylvania PPS* Hazard Planning Priority 1 Pandemic CRITICAL 2 Coastal Storm CRITICAL 3 Flood CRITICAL 4 Utility Interruption CRITICAL 5 Localized Infectious Disease CRITICAL 6 Winter Storm HIGH 7 Hazardous Material Release HIGH 8 Tornado HIGH 9 Conventional Explosive HIGH 10 Biological Terrorism MODERATE 11 Civil Disturbance MODERATE 12 Active Shooter MODERATE 13 Radiation Dispersal Device MODERATE 14 Drought MODERATE 15 Temperature Extremes MODERATE 16 Nuclear Facility MODERATE 17 Chemical Terrorism LOW 18 Fire LOW 19 Earthquake LOW 20 Cyber Terrorism LOW *PPS = Planning Priority Score 1 Critical scores greater than 15.6 High scores between Moderate scores between Low scores below 7.8 A-15

33 Figure 1. Hazards by Risk (Probability vs Severity) South Central Mountain Region, Pennsylvania Probability Severity 2.80 Figure 2. Hazards by Preparedness vs Adjusted Risk South Central Mountain Region, Pennsylvania Preparedness Adjusted Risk A-16

34 South East Region Table. Hazards in order of Planning Priority Score, South East Region, Pennsylvania PPS* Hazard Planning Priority 1 Pandemic CRITICAL 2 Coastal Storm CRITICAL 3 Flood CRITICAL 4 Utility Interruption CRITICAL 5 Localized Infectious Disease CRITICAL 6 Winter Storm HIGH 7 Hazardous Material Release HIGH 8 Tornado HIGH 9 Conventional Explosive HIGH 10 Nuclear Facility HIGH 11 Biological Terrorism MODERATE 12 Civil Disturbance MODERATE 13 Radiation Dispersal Device MODERATE 14 Drought MODERATE 15 Active Shooter MODERATE 16 Temperature Extremes LOW 17 Chemical Terrorism LOW 18 Fire LOW 19 Earthquake LOW 20 Cyber Terrorism LOW *PPS = Planning Priority Score 1 Critical scores greater than 15.6 High scores between Moderate scores between Low scores below 7.8 A-17

35 Figure 1. Hazards by Risk (Probability vs Severity) South East Region, Pennsylvania Probability Severity 2.85 Figure 2. Hazards by Preparedness vs Adjusted Risk South East Region, Pennsylvania Preparedness Adjusted Risk A-18

36 Appendix B. Description of Calculations in the PA Public Health Risk Assessment Tool The following sections describe in detail the scoring and calculations used to determine hazard-specific scores in the PA PHRAT. Probability The Probability Score of each hazard is assigned based on the following scoring scale. The system lifecycle used is 100 years: 0 = Improbable The probability of the occurrence of the hazard is zero 1 = Remote The hazard is not likely to occur in the system lifecycle, but it is possible 2 = Occasional The hazard is likely to occur at least once in the system lifecycle 3 = Probable The hazard is likely to occur several times in the system lifecycle 4 = Frequent The hazard is likely to occur cyclically or annually in the system lifecycle Severity The Severity Score is the average of the scores assigned to each of the five domains: human impact, healthcare service impact, inpatient healthcare facility infrastructure impact, community impact, and public health service impact. Each metric is scored from 0-4. The score for each of the five domains is the average of the scores for all the metrics within that domain. The severity scores for the overall analysis and each of the two sub-analyses are calculated using the following formulas: Severity Score = Human + HC Service + Inpt HC Facility Infrastructure + Community + PH Service 5 PH System Severity Score = HC System Severity Score = Human + HC Service + Community + PH Service 4 Human + HC Service + Inpt HC Facility Infrastructure 3 Table 1. Severity Metrics Domain Metric Score Based On: Human Impact Mortality Deaths/day EMS Transports Transports/day ED Visits ED visits/day Outpatient Visits Visits/day Trauma Center Injuries Trauma center injuries/day Mental Health Impact Percent of population developing psychopathology and behavioral changes after the incident, including PTST, depression, anxiety, alcohol and substance abuse, domestic violence, and loss of social functions Healthcare Outpatient Services PCPs supply/demand B-19

37 Service Impact Inpatient Healthcare Facility Infrastructure Impact Community Impact Public Health Service Impact Emergency Department Services Hospital Beds Ancillary Services Trauma Units Mental Health Services Hospital Personnel Facility Water Supply Facility Electricity Facility Generator Fuel Supply Hospital IT/Communication Systems Facility Critical Supplies Facility Evacuation Hospital Patient Decontamination Water Supply Sanitation/Sewage System Public Utilities Transportation Business Continuity Population Displacement Environmental Contamination Personnel Surveillance B-20 ED bed supply/demand Bed supply/demand Pharmacy supply/demand Functioning OR supply/demand Mental Health provider supply/demand Patient to nurse ratio Percent of Beds affected Hours without water in HC facilities Percent of Beds affected Hours without electricity in HC facilities Percent of Beds affected Hours of generator fuel required in HC facilities Percent of Beds affected Hours without access to EMRs/IT/communication systems Percent of Beds affected Days without linen service Percent of regional beds requiring evacuation Number of pts requiring decontamination, as percent of regional ED capacity Percent of population with water outage or mandatory boil water order Percent with sanitation/sewage system disruption Percentage of population with no access to electricity that at least ONE major transportation corridor is closed Percent of businesses are closed Number of persons evacuated from or to the jurisdiction Radius of area requiring environmental safety assessment, remediation, or decontamination Public health employee supply/demand Case reports requiring tracking, monitoring, investigation, or other public health

38 Mass Care Medical Countermeasures Laboratory Services Health Communication Fatality Management action/day Persons requiring mass care/sheltering/public health monitoring Percentage of population that requires medication or prophylaxis Specimens processed/day Personnel hours per week needed to generate health communications to external partners or general public Morgue capacity supply/demand Risk The Risk Score is calculated from the Probability Score and the Severity Score using the following equation: Probability Score Severity Score Risk Score = PH System Risk Score = HC System Risk Score = Probability Score PH System Severity Score Probability Score HC System Severity Score At-Risk Populations The At-Risk Populations Score reflects the amount of additional planning required for at-risk populations. Nine populations were selected to be assessed: persons with a hearing disability, persons with a vision disability, persons with an ambulatory disability, persons with a cognitive disability, persons with limited English proficiency, persons with income below the poverty level, persons with chronic diseases (diabetes is used as a proxy), children under 18 years, and the elderly (age 65 and older). The At-Risk Populations Score is calculated from a score assigned to the size of the population (the Population Size Score), and a score that reflects the unique planning needs of each of the nine selected at-risk populations in a given disaster scenario (the Access Planning Score). The Population Size Score is assigned based on the size of the population using the following scale: 0 = Population represents 0% of the total population 1 = Population represents more than 0% but less than 5% of the total population 2 = Population represents at least 5% but less than 10% of the total population 3 = Population represents at least 10% but less than 15% of the total population 4 = Population represents at least 15% of the total population The Access Planning Score is a sum of points assigned to four categories of emergency planning. One point is assigned for each of the following population needs for a given hazard, and the points are added together, generating a total score between zero and four: B-21