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Assessment of the community healthcare providers' ability and willingness to respond to a bioterrorist attack in Florida

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Assessment of the community healthcare providers' ability and willingness to respond to a bioterrorist attack in Florida
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Crane, Jeffrey S
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Subjects / Keywords:
Core competencies
Emergency preparedness planning
Public health preparedness
Terrorism
Strategic national stockpile
Dissertations, Academic -- Public Health -- Doctoral -- USF   ( lcsh )
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government publication (state, provincial, terriorial, dependent)   ( marcgt )
bibliography   ( marcgt )
theses   ( marcgt )
non-fiction   ( marcgt )

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Summary:
ABSTRACT: Previous findings have demonstrated that the preparedness and infrastructure of the public health system is inadequately developed for a biological and/or chemical terrorism attack.(1-4) Chen et al. reported that those primary care providers that would have to respond to such an attack do not feel prepared to diagnose and manage such an event.(5)This research was an observational study using e-mail/web based survey to assess the levels of preparedness (PL) and willingness to respond (WTR) to a bioterrorism attack, and identify factors that predict PL and WTR of Florida community healthcare providers. The conceptual framework and questionnaire was designed based on empirical studies and the use of an expert panel to assess the providers administrative and clinical competencies, WTR, and PL. The questionnaire was pilot tested in 30 subjects. Reliability was high (Cronbachs alpha =.82).The emailed invitaiton letters were sent to 22,800 healthcare providers in Florida. The questionniare was posted for 7 days on the website during December, 2004.There were 2,279 respondents of 9,124 who received the e-mails. Response rate was 28%, with 86% completed questionnaires. The subjects included physicians (n=604), nurses (n=1,152), and pharmacists (n=486). The results demonstrated that only 32% of the Florida providers were competent and willing to respond to a bioterrorism attack. 82.7% of providers were willing to respond in their local community and 53.6% within the State. The subjects were more competent in administrative skills than clinical knowledge (62.8% vs. 45%) The most competent areas were the initiation of the treatment and recognition of their clinical and administrative roles. The least competent areas were identifying the cases and communicate risk to the others.
Thesis:
Thesis (Ph.D.)--University of South Florida, 2005.
Bibliography:
Includes bibliographical references.
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Statement of Responsibility:
by Jeffrey S. Crane.
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Title from PDF of title page.
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Document formatted into pages; contains 173 pages.
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Includes vita.

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aleph - 001681082
oclc - 62750674
usfldc doi - E14-SFE0001034
usfldc handle - e14.1034
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ABSTRACT: Previous findings have demonstrated that the preparedness and infrastructure of the public health system is inadequately developed for a biological and/or chemical terrorism attack.(1-4) Chen et al. reported that those primary care providers that would have to respond to such an attack do not feel prepared to diagnose and manage such an event.(5)This research was an observational study using e-mail/web based survey to assess the levels of preparedness (PL) and willingness to respond (WTR) to a bioterrorism attack, and identify factors that predict PL and WTR of Florida community healthcare providers. The conceptual framework and questionnaire was designed based on empirical studies and the use of an expert panel to assess the providers administrative and clinical competencies, WTR, and PL. The questionnaire was pilot tested in 30 subjects. Reliability was high (Cronbachs alpha =.82).The emailed invitaiton letters were sent to 22,800 healthcare providers in Florida. The questionniare was posted for 7 days on the website during December, 2004.There were 2,279 respondents of 9,124 who received the e-mails. Response rate was 28%, with 86% completed questionnaires. The subjects included physicians (n=604), nurses (n=1,152), and pharmacists (n=486). The results demonstrated that only 32% of the Florida providers were competent and willing to respond to a bioterrorism attack. 82.7% of providers were willing to respond in their local community and 53.6% within the State. The subjects were more competent in administrative skills than clinical knowledge (62.8% vs. 45%) The most competent areas were the initiation of the treatment and recognition of their clinical and administrative roles. The least competent areas were identifying the cases and communicate risk to the others.
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Assessment of the Community Healthcar e Providers' Ability and Willingness to Respond to a Bioterrorist Attack in Florida By Jeffrey S. Crane, M.B.A., M.P.A. A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy Department of Environmental and Occupational Health College of Public Health University of South Florida Major Professor: Raymond D. Harbison, Ph.D. Jay Wolfson, Dr.Ph., J.D. M. Rony Francois, M.D. Ph.D. Wayne Westhoff, Ph.D. Date of Approval: April 15, 2005 Keywords: core competencies, emergenc y preparedness planning, public health preparedness, terrorism, Strategic National Stockpile Copyright 2005, Jeffrey S. Crane, All Rights Reserved.

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Dedication I would like to dedicate this dissertation to my Mother a nd Father for their selfless support over the years. I send all my Love.

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Acknowledgements I would like to thank Penkarn Kanjanarat for being a special person in my life. I would not have graduated without your support. I would like to acknowle dge my brother Brett Crane and his kids, Justin and Taylor. I w ould like to thank Nonna Klimchenkova for your help over the years. I owe tremendous gratitude to Dr. Raymond Harbison, Dr. Jay Wolfson, Dr. M. Rony Francois, and Dr. Wayne Westhoff who selflessly gave me their insigh ts and time over the years.

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TABLE OF CONTENTS List of Tables v List of Figures vii Abstract viii Chapter One: Introduction 2 Problem Statement 6 Specific Aims 9 Research Questions 9 Implications of this Study 11 Organization of the Dissertation 12 Definition of the Key Terms 13 List of Assumptions 14 Chapter Two: Literary Review 18 History of Bioterrorism 19 Bioterrorism Agents 21 Smallpox 23 Bioterrorism Preparedness Activities 24 The Strategic National Stockpile 27 Points of Distribution Centers 28 Bioterrorism and Epidemic Respons e Model (BERM) 29 Community Healthcare Providers’ Preparedness 30 Roles of Responding Healthcare Providers 31 Previous Studies 33 Bioterrorism Core Competencies 34 Selection of the Core Co mpetencies for this Study 35 Rationale and Conceptual Framework 38 Conceptual Framework of this Study 39 Data Collection Tools: a comparison am ong Web-based, e-mail, and traditional mail survey 41 Survey Techniques 44 Survey Population Coverage and External Validity 45 Response Rates 46 Time of Delivery and Response 46 Cost 47 Data Quality 48

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ii Chapter Three: Res earch Methodology 50 Study Design and Methodology 50 Survey Sample 52 Sample Calculations 52 Letters of Invitation 53 Research Instrument 54 Phases of Development 54 Data Collection 57 Data Preparation 58 Measurements 58 Willingness to Respond 59 Willingness to Respond in their Local Community 60 Willingness to Respond w ithin the Region (Surrounding Counties) 60 Willingness to Respond with in the State of Florida 61 Willingness to Respond Wi thin the United States 61 Administrative Competency Level (ACL) 62 Administrative Competency 1 (AC1) 63 Administrative Competency 2 (AC2) 63 Administrative Competency 3 (AC3) 64 Administrative Competency 4 (AC4) 64 Administrative Competency 5 (AC5) 65 Administrative Competency 6 (AC6) 65 Administrative Competency 7 (AC7) 66 Administrative Competency 8 (AC8) 66 Clinical Competency Level (CCL) 67 Clinical Competency 1 (CC1) 68 Clinical Competency 2 (CC2) 68 Clinical Competency 3 (CC3) 69 Clinical Competency 4 (CC4) 69 Clinical Competency 5 (CC5) 70 Clinical Competency 6 (CC6) 70 Clinical Competency 7 (CC7) 71 Clinical Competency 8 (CC8) 71 Bioterrorism Competency Level (BCL) 72 Preparedness Level (PL) 72 Perceived Benefits of Bi oterrorism Training (PBT) 73 Perceived Threats of the Risk of Bioterrorism Attack in the Local Community (PTR) 73 Healthcare Providers’ “F eeling Prepared” (FP) 74 Previous Participation in Preparedness Drills (PPD) 74 Previous Participation in Preparedness Trainings (PPT) 74 Data Analysis 75 Chapter Four: Results 82

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iii Distribution of th e Questionnaire 82 Description of the Study Subjects 83 Description of the Subjects’ Work Place 84 Assessment of the Provider’s Current Preparedness Levels 85 Determine the Providers’ Competency Levels (AC1-8 and CC1-8) 86 Administrative Competencies (AC) 86 Clinical Competencies (CC) 88 Administrative Compet ency Level (ACL) 90 Clinical Competency Level (CCL) 91 Bioterrorism Competency Level (BCL) 92 Willingness-to-Respond 92 Willingness to Respond within their local community 92 Research Question 6. 92 Willingness to Respond outside their local community 93 Research Question 7. 93 Provider Preparedness Level (PL) 94 Research Question 1. 95 Research Question 2. 96 Research Question 3. 97 The Work Place Emergency Plan 98 Emergency Preparedness Drills 99 Emergency Preparedness Training Activities 100 Method / Modality of Bioterro rism Training Received 101 Perceived Benefits of Biot errorism Training (PBT) 102 Perceived Threats of the Risk of a Bioterrorism Attack 103 Predictive Factors of Provid er Preparedness Levels 104 Research Question 4 104 Research Question 5. 106 Research Question 8. 108 Research Question 9. 111 Research Question 10. 112 Research Question 11. 113 Chapter 5 Discussion 117 Evaluation of the Demographic Factors 117 The Questionnaire 118 The Assessment of the Provide rs Competency Levels 120 The Individual Core Competencies 120 The Administrative Competen cy Level and Clinical Competency Level 122 The Bioterrorism Competency Level 122 The Assessment of the Providers Willingness to Respond 123 The Assessment of the Providers Ov erall Preparedness Level (PL) 126 List of Study Limitations 129 Conclusion and Implications 131 References 133

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iv Appendices 139 Appendix A: Questionnaire 140 About the Author End Page

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v LIST OF TABLES Table 1-1 Terrorist Attacks on the United States Abroad 6 Table 1-2 Staffing Calculati ons for a Florida Bioterro rism Response using the Weill/Cornell Bioterrorism and Epidemic Response Model (BERM). 8 Table 2-1 The Core Competency List as modified by experts for this study. 37 Table 4-1 Florida Hea lthcare Providers’ Demographics 83 Table 4-2 Florida Healthcare Pr oviders’ Work Place Demographics 84 Table 4-3 Administrative Competency Le vels of Florida Healthcare Providers 88 Table 4-4 Clinical Competency Leve ls of Florida Heal thcare Providers 90 Table 4-5. Percentage of Florida Hea lthcare Providers Willi ng-to-Respond to a Bioterrorism Attack 93 Table 4-6. Preparedness Levels of Florida Healthca re Providers 95 Table 4-7 Descriptive Statis tics of the Variables in th e Logistic Regression Model for Question 4. 104 Table 4-8 Logistic Re gression Significant Results for Question 4 104 Table 4-9 Model Summary for Question 4 104 Table 4-10 Model Prediction for Question 4 105 Table 4-11 Descriptive Statis tics of the Variables in th e Logistic Regression Model for Question 5. 107 Table 4-12 Logistic Re gression Significant Results for Question 5 107 Table 4-13 Model Summary for Question 5 107 Table 4-14 Model Prediction for Question 5 107

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vi Table 4-15 Logistic Re gression of Significant Re sults for Question 8 109 Table 4-16 Model Summary for Question 8 109 Table 4-17 Model Prediction for Question 8 110 Table 4-18 Logistic Re gression Significant Results for Question 9 111 Table 4-19 Model Summary for Question 9 111 Table 4-20 Model Prediction for Question 9 112 Table 4-21 Logistic Re gression Significant Resu lts for Question 10 112 Table 4-22 Model Summary for Question 10 113 Table 4-23 Model Prediction for Question 10 113 Table 4-24 Logistic Re gression Significant Resu lts for Question 11 114 Table 4-25 Model Summary for Question 11 114 Table 4-26 Model Prediction for Question 11 115

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vii LIST OF FIGURES Figure 1-1 FEMA’s Biological Incident Life Cycle without Preparedness 5 Figure 2-1 Conceptual Fr amework of the Study 38 Figure 2-2 Predictive Model of the Theory of Planned Behavior 40 Figure 3-1 Weighted Competency Values 57 Figure 3-2 “Willingness to Respon d”Proximity of the Events 59 Figure 4-1. Provider Admi nistrative Competency Le vels for Bioterrorism Preparedness. 87 Figure 4-2. Provider Clinical Competency Levels for Bi oterrorism Preparedness 89 Figure 4-3. Weighted Biot errorism Competency Leve ls Scores for Florida’s Healthcare Providers. 91 Figure 4-4. The Scored Conceptual M odel for Bioterrorism Preparedness. 94 Figure 4-5. Overall Bioterrorism Prepar edness Level (PL) by Provider Type. 96 Figure 4-6. Percentage of Provi ders that “Feel” Prepared. 97 Figure 4-7. Provider’s Knowledge of a Wo rk Place Emergency Plan and It’s Contents 98 Figure 4-8. Provider’s Par ticipation in an Emergenc y Preparedness Drills 99 Figure 4-9. Provider’s Emergency Preparedness Training Activities 100 Figure 4-10. Types of Biot errorism Training Methods/ Mo dalities for Providers 101 Figure 4-11. The Prov iders’ Perceived Benefits of Bi oterrorism Training (PBT) 102 Figure 4-11. The Provid ers Perceived Threats of the Risk of a Bioterrorism Attack at the State and Local Levels 104

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viii ASSESSMENT OF THE COMMUNITY HEALTHCARE PROVIDERS' ABILITY AND WILLINGNESS TO RESPOND TO A BIOTERRORIST ATTACK IN FLORIDA Jeffrey S. Crane ABSTRACT Previous findings have dem onstrated that the preparedne ss and infrastructure of the public health system are inadequately de veloped for a biological and/or chemical terrorism attack. (1-4) Chen et al. reported that those prim ary care providers that would have to respond to such an at tack do not feel prepared to diagnose and manage such an event.(5)This research was an observational study using e-mail/web based survey to assess the levels of preparedness (PL) and willi ngness to respond (WTR) to a bioterrorism attack, and identify factors that predict PL and WTR of Florida community healthcare providers. The conceptual framework and questionnaire was designed based on empirical studies and th e use of an expert panel to a ssess the providers’ administrative and clinical competencies, WTR, and PL. The questionnaire was pilot-tested in 30 subjects. Reliability was high (Cronbach’s alpha =.82). The ema iled invitaiton letters were sent to 22,800 healthcare providers in Florida. The questionniare was posted for 7 days on the website during December, 2004. There were 2,279 respondents of 9,124 who received the e-mails. Response rate was 28%, with 86% completed questionnair es. The subjects included physicians (n=604), nurses (n=1,152), and pharmacists (n =486). The results demo nstrated that only

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ix 32% of the Florida providers were competen t and willing to respond to a bioterrorism attack. 82.7% of providers we re willing to respond in th eir local community and 53.6% within the State. The subjects were more competent in administrative skills than clinical knowledge (62.8% vs. 45%). Th e most competent areas we re the initiation of the treatment and recognition of thei r clinical and administrative roles. The least competent areas were identifying the cas es and communicate ri sk to the others. About 55% of the subjects had previous bioterrorism traini ng and 31.5% had emergency drills. Gender, race, previous training and dril ls, preceived threats of biot errorism attack and preceived benefits of training and drills and “feeling” prepared were the predictors of overall preparedness. The findings suggest that only one-third of Flor ida community healthcare providers were prepared for a bi oterrorism attack. To effect ively plan for a bioterrorism attack it is important to targ et the interventions to improv e clinical knowledge in every healthcare profession.

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“ … you asked me what keeps me awake at night, and that bothers me… this biological issue…” President Bill Clinton, 1991

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2 CHAPTER 1 INTRODUCTION Over the past century, wea pons of mass destruction (W MD) have been introduced by nation states at an increasi ng rate. Thirteen nation states are currently suspected in either possessing weaponized bi ological agents a nd/or having an offensive production program (6). These include the seven U.S. designated terrorist nation states (state sponsored terrorism Cuba, Ir an, Iraq, Libya, North Korea, Syria, and Sudan)(7). The ability to produce biological and chemical agents by locali zed terrorist groups has also been proven with incidences such as the 1994 Matsumoto sarin attack (7 dead, 600 injured), the 1995 sarin attack in the Tokyo subway system (5 dead, 565 hospitalized)(8), and the 1998 Wakayama arsenic incide nt (4 dead, 67 injured)(9). Prior to the September 11, 2001 attacks, the average American citizen had not been directly affected by a terrorist attack. These attacks were the first highly lethal confrontation by a foreig n force on the U.S. mainland since the War of 1812. Before this, most of the acts of terrorism were targeted abroad to the U.S. military personnel and U.S. Foreign Service government employees (see Table 1-1 for complete lis ting of attacks). In total, 18 known fatal terrorist attacks against the United Stat es (abroad) were perpetrated by foreign radical Islamists since 1983. Th e Oklahoma City bombing and the 1993 World Trade Center bombing being the exceptions, even th en the responsible individuals were apprehended. These facts allowed average Americans to apply the “Out-of Sight”, “Out

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3 of Mind” way of thinking and no t view the attacks as a direct threat to them and to their way of life. However, the September 11th attacks that k illed thousands of innocent people (Flight 93, Pentagon and Worl d Trade Center) and was repl ayed on national television around the clock, did demonstrat e to U.S. government offici als, and to the average citizen, that foreign terrorist s had the resolution and capabi lity to plan, organize, and execute attacks that can produ ce mass casualties to Americans on the U.S. mainland (10). These terrorist attacks brought a dramatic change to the wa y Americans live their lives and view terrorism. Americans were i mmediately on high alert and the preparedness activities to prevent another su ch “airliner” attack had begun. In the months following the September 11th attacks, the dispersal of anthrax spores via the U.S. Postal Service further ra ised questions concerni ng the United States’ ability to prevent and respond to not only “traditional” terrorism attacks such as bombings and shootings, but also to biological and chemical events. While the history of global warfare has demonstrat ed the effective use of micr obial agents by government entities as weapons of war, biological terrori sm was previously deem ed an unlikely event in the U.S. by most terrorism experts. And when used in th e past, targets of biological warfare were normally deemed as a military objective. (11) The military use of biolog ical agents has been ba nned since the 1974 Biological Weapons Convention Signing (12) and its military use was no rmally for genocide (e.g. Smallpox contaminated blankets given to Indi ans). Now, it is the unsuspecting civilian populations that are the most likely targets by terrorists because even a small number of deaths, as experienced with the 2001 anthrax attacks (total of 5 deaths), produced great

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4 terror in the U.S. population, thus causing critical parts of th e nation’s infrastructure to virtually shut down (U.S. Postal System and the U.S. Senate). This potential to cause terror with the threat of a biological agent is why the term “bioterro rism” was coined. As demonstrated by the 2004 Nation al Elections in Spain, an ac t of terror (train bombing) could be used to advance the ideologies of the terrorist groups by influencing a regime change when correctly applied (Mad rid, Spain, 199 dead, 1450 wounded). The technological advances in production and the desi re, have made weaponized biological agents as capable as a nuclear weapon to produce mass terror and causalities, but at a fraction of the cost. ( 13) The previous terrorist succes ses, such as in the Madrid example and September 11th, and the advances in production, motivat es terrorist groups to obtain known weaponized bi ological and chemical agents or search out other agents commonly available. So each year more chemical a nd biological agents have to be added to the list of possible wea pons that could be used ag ainst civilian populations. With the introduction of each new potential agent, Florida’s community healthcare providers are faced with making a correct diagnosis in their medical setting, reporting it to the correct aut hority, and the possibility of responding as an agent of the Florida Department of Health. While medical practice has always been considered the science of probability and the art of uncertainty, it is rec ognized that uncertainty is prevalent in health car e practices and that uncertainty is a crucial factor in decisionmaking. However, literature on how physicia ns, pharmacists and nurses make judgments under uncertain conditions is fu ll of controversy. (14) Clearly, formal and informal education and training has advanced healthcar e providers’ ability to correctly improve patients’ health status an d quality of life over the last 100 years during normal

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5 circumstances, but with the added factors attributed to weaponized biological and chemical agents released in a civilian population, it is uncertain whether Florida providers are able and willing to make crucial decisions without having basic competencies in bioter rorism identification and manageme nt, and the willingness to care for infected patients. The introduction of awareness level biot errorism trainings and seminars for healthcare providers since the 2001 anthrax attacks s hould have improved the bioterrorism competency levels of community providers and their willingness to respond. Without access to a prepared workforce of community healthcare providers during a bioterrorism attack within Flor ida, the biological incident li fe cycle would result in chaos of Florida’s population (see Figur e 1-1). This will provide fo r an increase in morbidity and mortality rates in Florid a’s population and the spread of the disease across the U.S., and the World. Figure 1-1. Biological Incident Li fe Cycle without Preparedness. Source: Adapted from Federal Emergency Management Agency (FEMA) information.

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6 Problem Statement Previous findings have dem onstrated that the preparedne ss and infrastructure of the public health system are inadequately de veloped for a biological and/or chemical terrorism attack (1;2;4;15). Additionally, it was found that those primary care providers that would have to respond to such an attack do not “f eel” prepared to diagnose and manage such an event. (5) Since these studies were orig inally published in 2002, the State of Florida with the support of federal government agencies became recognized as one of the national leaders of Public Health Preparedness. (16) Even so, the inherent shortfalls of the bioterrorism planning process within the St ate of Florida and its contractors led to the questionable ability to effectively activate the bioterrorism plans duri ng an actual response to a largescale biological event without the support of th e local community h ealthcare providers (physicians, nurses a nd pharmacists). Table 1-1. Select Terrorist Attack s on the United States Abroad Event Location Results 1983 U.S. Embassy bombing Beirut, Lebanon 63 dead 1983 U.S. Embassy bombing Kuwait 6 dead 1984 U.S. Marine barracks bombing Beirut, Lebanon 241 dead 1985 U.S. Embassy bombing Beirut, Lebanon 24 dead 1985 U.S. Military base bombing Frankfurt, Germany 3 dead 1996 Khobar Towers Saudi Arabia 19 dead, 515 wounded 1998 U.S. Embassy bombings Nairobi, Kenya 301 dead, over 5000 injured 1998 U.S. Embassy bombings Dar-es-Salaam, Tanzania 301 dead, over 5000 injured 2000 USS Cole Aden, Yemen 17 dead, 39 injured Using the recommended planning me thodology advocated by the Florida Department of Health and its contractors, the aver age local county emergency management plans’ (CEMP) strategic national stockpile and mass casualty attachments,

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7 normally located in the Emergency Support Fu nction (ESF) 8, Health and Medical annex, as written would require on average over 97% of the licensed hea lthcare providers to come from the local community and/or outside the affected county to fully activate (1721). As an example, the Da de County Health Department serves a population of 2.25 million and has 864 employees with approxi mately 23% core licensed medical professionals (physicians, nurse s and pharmacists). Using the State template, in a largescale biological event, Da de County Health Departme nt's plan would require 15,589 persons with 10,048 being core licensed medi cal personnel to ad minister smallpox vaccinations to its population. This is a pl anning shortfall of 14,725 total personnel with 9,849 in core medical personnel The whole population of the State of Florida would require 117,846 total persons and 75,968 core medical personnel (s ee Table 1-2 for a complete list of Florida st affing calculations). Thus, th eoretically, when the counties developed these response plans, it must have been assumed that the community health care providers have the basic competencies to identify and manage a biological terrorism attack, and are willing to res pond to a bioterrorism event. This study was motivated by the recognized threat of weap onized biological agents, such as Smallpox, being releas ed upon Florida’s p opulation and the uncer tainty that the planning efforts by the State of Florida si nce 2001 could become operative during a biological terrorism attack. Specifically, this study took an empirically-driven approach in the assessment of Flor ida’s community healthcare providers’ current preparedness levels, the factors that influenced these le vels, and the willingnes s of the provider to respond to a bioterrorist attack within the St ate of Florida. The study’s findings may be used for policy assessm ent and planning purposes.

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8 Table 1-2. Staffing Calculations for a Fl orida Bioterrorism Response using the Weill/Cornell Bioterrorism and Epidemic Response Model (BERM). (Based on Smallpox, 5 day response,16 hrs per day with15% downtime.) Count y PopulationSeasonalTotal PoPCore StaffSupport StaffTotal Staff Alachua 217,95536,359254,3149945481,542 Baker 22,2593,77326,03215987246 Bay 148,21721,223169,4406633651,028 Bradford 26,0883,57329,66115987246 Brevard 476,23077,252553,4822,1641,1933,357 Broward 1,623,018367,5301,990,5487,7844,29212,076 Calhoun 13,0172,00615,02313775212 Charlotte 141,62730,652172,2796743711,045 Citrus 118,08524,570142,655558308866 Clay 140,81434,828175,6426873791,066 Collier 251,37799,278350,6551,3727562,128 Columbia 56,51313,90070,413275152427 DeSoto 32,2098,34440,55315987246 Dixie 13,8273,24217,06915987246 Duval 778,879105,908884,7873,4601,9085,368 Escambia 294,41031,612326,0221,2757031,978 Flagler 49,83221,13170,963277153430 Franklin 11,0572,09013,14715987246 Gadsden 45,0873,98249,069192106298 Gilchrist 14,4374,77019,20715987246 Glades 10,5762,98513,56115987246 Gulf 13,3321,82815,16015987246 Hamilton 13,3272,39715,72415987246 Hardee 26,9387,43934,37715987246 Hendry 36,21010,43746,647182101283 Hernando 130,80229,687160,489628346974 Highlands 87,36618,934106,300416229645 Hillsborough 998,948164,8941,163,8424,5512,5107,061 Holmes 18,5642,78621,35015987246 Indian River 112,94722,739135,686531293824 Jackson 46,7555,38052,135204112316 Jefferson 12,9021,60614,50815987246 Lafayette 7,0221,4448,46615987246 Lake 210,52858,424268,9521,0525801,632 Lee 440,888105,775546,6632,1381,1793,317 Leon 239,45246,959286,4111,1206181,738 Levy 34,4508,52742,97716893261 Liberty 7,0211,4528,47315987246 Madison 18,7332,16420,89715987246 Manatee 264,00252,295316,2971,2376821,919 Marion 258,91664,083322,9991,2636961,959 Martin 126,73125,831152,562597329926 Miami-Dade 2,253,362316,2682,569,63010,0485,54115,589 Monroe 79,5891,56581,154317175492 Nassau 57,66313,72271,385279154433 Okaloosa 170,49826,722197,2207714251,196 Okeechobee 35,9106,28342,19316591256 Orange 896,344218,8531,115,1974,3612,4056,766 Osceola 172,49364,765237,2589285121,440 Palm Beach 1,131,184267,6661,398,8505,4703,0168,486 Pasco 344,76563,634408,3991,5978812,478 Pinellas 921,48269,823991,3053,8762,1386,014 Polk 483,92478,542562,4662,1991,2133,412 Putnam 70,4235,35375,776296163459 St. Johns 123,13539,306162,441635350985 St. Lucie 192,69542,524235,2199205071,427 Santa Rosa 117,74336,135153,878602332934 Sarasota 325,95748,181374,1381,4638072,270 Seminole 365,19677,667442,8631,7329552,687 Sumter 53,34521,76875,113294162456 Suwannee 34,8448,06442,90816893261 Taylor 19,2562,14521,40115987246 Union 13,4423,19016,63215987246 Volusia 443,34372,631515,9742,0181,1133,131 Wakulla 22,8638,66131,52415987246 Walton 40,60112,84153,442209115324 Washington 20,9734,054 25,02715987246 FLORID A 15,982,3783,044,452 19,026,83075,96841,878117,846

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9 Specific Aims This study was designed to serve three major purposes: 1) to give insight into Florida’s community healthcare providers’ clinical and administrative competencies to manage a bioterrorism attack, 2) to give insight into thei r willingness to respond to a biological terrorism attack within the State of Florida, and 3) to assess the current level of preparedness of Florida’s community health care providers (physic ians, pharmacists and nurses) to identify and manage a biological terrorism attack. Research Questions 1. Are Florida’s community healthcare providers (physicia ns, pharmacists and nurses) prepared to identify and manage a bioterrorism attack? 2. Are the levels of preparedness to res pond to a bioterrorism attack different among physicians, pharmacists, and nurses? H1: Florida’s physicians, pharmacists and nurses are not equally prepared to identify and manage a biological terrorism attack. 3. Do Florida’ healthcare providers (p hysicians, pharmacists and nurses) “Feel” prepared to identify and manage a bioterrorism attack? 4. Do previous emergency preparedness trainings and dr ills predict the overall level of preparedness of the healthcare providers? H1: Previous emergency preparedness trainings and drills predict the overall level of preparedness of the healthcare providers. 5. Do previous emergency preparedness trainings and dr ills predict the Florida’s healthcare prov iders’ willingness to respond to a biological terrorism attack within the State of Florida?

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10 H1: Previous emergency preparedness trainings and drills predict the willingness of the comm unity healthcare providers to respond to a biological terrorism attack w ithin the State of Florida. 6. Are Florida’s community healthcare providers (physicia ns, pharmacists and nurses) willing to respond to biologi cal agent attacks within their local community ? 7. Are Florida’s community healthcare providers (physicians, pharmacists and nurses) willing to respond to biological agent attacks outside their local community (statewide) ? 8. Do demographic factors of Florid a’s community healthcare providers (physicians, pharmacists and nurses) pr edict a biological terrorism overall level of preparedness? H1: Demographic factors of Florida’s community healthcare providers (physicians, pharmacists and nurses) predict a biological terrorism overall level of preparedness. 9. Does the perceived benefit of bioterro rism preparedness training predict the overall level of preparedness of the healthcare providers? H1: The perceived benefit of bioterro rism preparedness training predicts the overall level of preparedness of the healthcare provider. 10. Does the perceived threat that a provid er's community is at real risk of a bioterrorism attack predict the ov erall level of preparedness of the healthcare providers?

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11 H1: The perceived threat that a provider 's community is at real risk of a bioterrorism attack predicts the ov erall level of preparedness of the healthcare provider. 11. Do the demographics, perceived threat of bioterrorism attack, perceived benefits of bioterrorism training, prev ious trainings, and previous drills predict the level of preparedness of the healthcare providers? H1: The demographics, perceived threat of bioterrorism attack, perceived benefits of bioterrorism training, pr evious trainings, and previous drills predict the level of preparedne ss of the healthcare provider. Implications of this Study The findings of this study will allow fo r the future development of training, mobilization and management models for health care personnel to ad equately respond to a public health crisis. It will also set the base line value to evaluate future public health preparedness activities in the State of Florida and could be used as a benchmark for public health preparedness levels for across the nation. This study directly assesses the current levels of preparedness of Florid a’s community health care providers’ core bioterrorism competency levels and their wi llingness to respond to biological terrorism attack. This will help identify possible w eaknesses in current “planned” public health responses to a biological terro rism attack within the Stat e of Florida, and across the nation. Based on the results of the survey, tools and models can also be developed to help increase the health car e system’s readiness for a biot errorism event and other public health crisis (e.g. SARS) in Fl orida. Training models base d on the study’s findings can

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12 be used to enable educational facilities (universities and continui ng education programs) the ability to efficiently and successfully integrate public health emergency readiness competencies within esta blished training programs of healthcare personnel. The questionnair e that was developed for this study and tested for its validity and reliability can be used to assess the level of preparedness to respond to a bioterrorism attack in other states, in a cer tain type of healthcare providers or a certain situation (e.g., anthrax event). This questi onnaire also can be used fo r a healthcare institution which would want to assess the preparedness of its providers and develop its own training. The methodology to identify ad ministrative and clinical competencies, willingness to respond, and overall preparedness can be uti lized as a model to ta rget for training of healthcare providers, and for future research. Organization of the Dissertation Chapter 1, Introduction, examin ed the history of terrori sm and problems that are faced by Florida’s healthcare pr oviders. It stated the specifi c aims that the study will focus upon, and listed the research questions and impli cations for this study. The remainder of this chapter will define the key terms used in this dissertation and by individuals in the fields of public health preparedness and emergency management. It will also list the assumptions made a nd the known limitations of this study. Chapter 2, Literature Review, will discu ss the development of the conceptual framework for this study a nd the use of the Public He alth Workers’ Emergency Preparedness Core Competencies for Emer gency Response and Bi oterrorism and the Clinician Competencies in Ini tial Assessment and Management (22). It also will examine

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13 all the relevant literature and studies on provider prepared ness levels, public health preparedness, bioterrorism pr eparedness and the administ ration of online surveys. Chapter 3, Research Methodology, will addr ess the methods used in this study. This includes the determination of the sa mpling frame and survey sample size, the methods for collecting the data including the letters of i nvitation and the design of the questionnaire. This chapter also looks at the measuremen ts used to determine the competency levels of the pr oviders and their willingness to respond and discusses how the data will be analyzed. Chapter 4, Results, will describe the dist ribution of the ques tionnaire, and the descriptions of the study subject s and their work place. It wi ll also detail the assessment of the healthcare providers’ competency levels and willingness to respond which determined the overall preparedness level of Florida healthcare providers. Finally, it will present the findings of the pr edictive modeling of an indivi dual’s overall preparedness level. Chapter 5, Discussion, will discuss Florid a’s community healthcare providers’ clinical and administrative competencies to manage a bioterrorism attack, the providers willingness to respond to a biological terrorism attack within the State of Florida, and their current level of overall preparedness to identify and manage a biological terrorism attack. This chapter also provides discus sions on the study results methodology, and its limitations.

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14 Definition of the Key Terms BioterrorismTh e act of terrorism using biol ogical agents (see Terrorism below). Public Health Core CompetencyIt is an area of expertise that is a basic and necessary component to public health work ers. An example of a bioterrorism response core competency for public health worker is the ab ility to use a fax machine. It is not nu clear response training for all workers in the public health system. SmallpoxSmallpox is a highly contagi ous, virulent, and often fatal disease caused by variola virus, a large orth opoxvirus of the fa mily Poxviridae, subfamily Chordopoxvirinae. (23) Strategic National Stockpile (SNS) “T he SNS is a national repository of antibiotics, chemical antidotes, antito xins, life-support medications, IV administration, airway maintenance suppl ies, and medical/surgical items. The SNS is designed to supplement and re -supply state and local public health agencies in the event of a national emer gency anywhere and at anytime within the U.S. or its territories.” (24) Terrorism“Acts dangerous to human life that are a violation of the criminal laws of the United States or any state and appear to be intended to intimidate or coerce a civilian population, influenc e the government by intimidation or coercion, or to affect the conduct of a government by mass destruction,

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15 assassination, or kidnapping, occurri ng primarily within the territorial jurisdiction of the United States.” (18 United States Code 802) Terrorist Nation States – These are Nations that fund terrorism. War of 1812A war (1812-1814) betwee n the United States and England which was trying to interfere with Amer ican trade with France, and it is the war that inspired the National Anth em (The Star Spangle Banner). List of Assumptions 1. Staffing Calculations for a Florida Bioterrorism Res ponse using the Weill/Cornell Bioterrorism and Epidemic Response Model (BERM) were based on the 2000 U.S. Census. It is assu med that Florida co unties that were not examined also took the recommenda tion of the Florida Department of Health and its contractors, and used th e BERM to calculate personnel needs. The BERM seems to be the standard method of calculation; it is used by Texas and other states (25). 2. In a large scale event, th e first responders and em ergency room workers will become infected as undiagnosed patients are transported to hospitals, thus they should not have a ma jor role in the plans. These workers will be essentially the warning “Can aries” that alert the hea lth care system of a major problem. 3. Healthcare providers who are employed by hospitals should not be used or be relied upon to respond to a larg e scale crisis. Th ese facilities are already short

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16 in personnel and are needed to keep th e hospital functioning. In most cases, the hospital systems rely upon each other. If one hospital fails, all other hospitals will have a problem keeping the doors open. 4. Large numbers of healthcare providers will refuse to work because of the fear of becoming ill and/or placing their ow n family at harm by working. (26) 5. The “worried well” will overw helm the healthcare system.

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17 “But the most troubling threat, in my judgment, is biological weapons. They may be quite small, and the raw material for some of the most fearsome ones such as anthrax is readily available, unlike fissionable material.” Testimony of R. James Woolsey U.S. House of Representatives Committee on National Security 22 February 12, 1998

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18 CHAPTER 2 LITERATURE REVIEW To better understand current US prepared ness activities and the need to have a prepared volunteer workforce of community hea lthcare providers to re spond to biological terrorism events, this ch apter will first discuss the risks of bioterrorism in the United States, the State of Florida and its local co mmunities, types of biol ogical agents that could be used for bioterrorism attacks and th e possible damage from such attacks. Second, a discussion on the current planning activities within the State of Florida and the methods that will keep the population protected and/or treated will be discussed. Third, the researcher will pr ovide literature review on current preparedness levels of healthcare providers within the United States and their willingness to respond. Forth, core competencies that have been used for asse ssment of preparedness and willingness to respond to bioterrorism attacks will be discussed. Fifth, the resear cher will exam the psychosocial theory, Theory of Planned Behavior, that is used in the theoretical framework as factors related to preparedne ss and willingness of healthcare providers. Sixth, the conceptual fr amework for this study will be disc ussed. Finally, the use of an mixed model (email/web) survey verses a traditional mail survey will be examined.

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19 History of Bioterrorism The use of disease as a weapon of war is as old as war itself. Water supplies have been contaminated with animal and human co rpses as early as th e 1346 Tartar siege of the seaport of Kaffa. It was stated that pl ague victims were catapulted over the walls of the besieged city. (27) To devastate the opposing forces du ring the French and Indian War of 1763, British soldiers presented sma llpox infested blankets and handkerchiefs to Native Americans (28), kill ing large portions of the i ndigenous population. During World War II, the Japanese used flea-borne plague to attack cities in China. Their infamous Unit 731 used soldiers and civilian s alike to conduct its experiments with biological weapons. (29) By the 1950s, several countries including the Soviet Union and the United States had extensive biological wea pons programs. These programs were weaponizing bacteria, biotoxins and viruses to be di spersed in aerosols, bombs and missiles. (30) The Soviet program had over 50,000 scientists and tec hnicians dedicated to biological weapons productions (six research labs and five production plants). (31) The total production capacity of all of th e facilities involved was many hundred s of tons of various agents annually. On April 10, 1972, the Biological Weapons Convention, after much debate, was signed. Under the terms of the Convention, no parties thereto would undertake the development, production, stockpiling, or acquire biological agents, toxi ns or the means of its delivery. This agreement also stated that all such materi als would be destroyed within nine months once the Convention entered into force. The United States announced its compliance to the Convention on December 26, 1975. (32) Then, in 1979, an accidental release of weaponized anthrax from a S oviet production plant killed 70 people in

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20 Sverdlovsk and injured countl ess others. (33) This event illustrated the deadly effectiveness of biolog ical warfare in the modern age and the ineffectiveness of the Biological Weapons Convention. In the 1980s, it was demonstrated that terrorist groups ha d the desire and capability of weaponizing and use of biological weapons. These groups were smaller in size and independent of a Nation State. Th e Rajneeshee Cult (1984) used Salmonella to contaminate salad bars in an attempt to in fluence a local election in Oregon. It did succeed in infecting 751 residents of that co mmunity, but the fact that it was a biological attack went undiscovered for six months before one of th e group’s members confessed. (34)This demonstrated the diff iculties in the detection of a small bioweapon attack. In 1995, another attack involved the Aum Shinriky o Doomsday Cult in Ja pan. Its attack of the Japanese subway system using sarin gas not only demonstrated the successful aerial dispersal of nerve agent by a small terrorist group, but the inabili ty of healthcare providers to effectively respond to such attack. Many of the first responders and hospital personnel were affected by the gas due to the lack of or im proper decontamination of the presenting patients. After further investiga tion into the Shinrikyo Cu lt, it was revealed that it also attempted to release anthrax fro m the rooftop of a T okyo building in 1993. No casualties were reported because the cult did not understand air flow dynamics in a city. If the cult had a better unders tanding and released the spores at a diff erent time during the day, it may have resulted in a quite different outcome. During 1998 and early 1999, a large number of letter s containing white power were received by businesses, targeted indivi duals and governmental offices in the United States. These letters were accompanied by phone cal ls threatening an anthrax attack. (28)

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21 Even though these letters tu rned out to be hoaxes w ith benign powers ranging from cornstarch to baby power, it was a precurso r to the 2001 attacks. Events during the Clinton Administration, which included thes e 1998 white power lette rs, the fall of the U.S.S.R. and the unemployed w eapons scientists, Iraq and high profile terrorist attacks in the United States and abroad, galvanized th e U.S. Congress to re focus on the civilian biodefense program in 1999. Congress allo cated $121 million to be used by the CDC to improve its bioterrorism det ection and response capabilitie s and to help establish a national pharmaceutical stockpile (later rename d to the Strategic Natio nal Stockpile). (3) Shortly after the September 11th, 2001 terrorist attacks, letters laced with weaponized anthrax began arriving to members of the media and high ranking government officials via the U.S. Postal System. The letters resulted in 22 identified cases of anthrax between October and Novemb er of 2001. Of these cases, eleven were inhalational anthrax resulting in five deaths. (3 5) The cases occurred on the eastern coast (Connecticut, District of Co lumbia, Florida, New Jersey and New York City) and produced massive anxiety throughout the United States. It disr upted critical services to the United States, such as mail delivery and the U.S. Senate. This attack confirmed that even a small bioterrorism attack (5 deaths) upon the citizens of the United States has the ability to cause mass terror in the population. It also dem onstrated the in ability of the public health system to effectively iden tify and respond to biological agents. Bioterrorism is a rec ognized threat to the popul ation of Florida and the United States. Massive funding for the planning and respons e to a biological w eapon has taken place since theses attacks. The Florida Depa rtment of Health (FDOH) has received $111 million alone for bioterrorism durin g fiscal years 2003 and 2004. (16)

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22 Bioterrorism Agents Since there are numerous agen ts capable of being used as a potential biological weapon, the CDC developed a list that categorizes agents in th e order of the seriousness of concern they present. The agents are re viewed annually and ar e either placed in Category A, B, or C. Agents in Category A are considered the most dangerous because they are easily disseminated, highly contagious and can be weaponized. They have the ability to cause mass causalit ies and are hard to manage without a sophisticated public health system response. (36) These agents include anthrax ( Bacillus anthraces ), botulism ( Clostridium botulinum ), plague ( Yersinia pestia ), smallpox ( Variola major ), tularemia ( Francisella tularensis ), and viral hemorrhagic fevers (Filoviruses and Arenaviruses). (37) The Category B agents are moderately easy to disseminate, produce moderate morbidity and low mortality, and are normally delivered in contam inated water and food sources. These agents include, but not limited to brucellosis ( Brucella species), cholera ( Vibrio cholerae), ricin toxin ( Ricinus communis), salmonella, and viral encephalitis. (37) These agents also require enhancements to disease surveillance and diagnostics systems to detect. The Category C agents are emerging pathog ens that have the potential to be weaponized for mass dissemination. (36) Th e agents are include d in this category because of their availability, ease of product ion and its potential to cause high morbidity and mortality. These agents include emerging in fectious diseases such as the Nipah virus and hantavirus. (37)

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23 Smallpox Smallpox is contagious and sometimes fa tal infectious disease, which has no specific treatment. The only prevention for the smallpox di sease is vaccination. The name smallpox means “spotted” in Latin. It refers to the raised bumps that appear on an infected person. It was once a global disease, bu t was declared erad icated in 1980 by the World Health Organization (WHO) after a successful wo rldwide vaccination program (38). In the United States, the last case of smallpox was in 1949, and the last naturally occurring case in the world was in 1977. This was accomplished by the general vaccination program that ended in the 1970s in the United States and 1982 worldwide. Since the anthrax attacks in 2001 and the potential of sm allpox being used as a bioweapon, the vaccination of the U.S. population began again. In Florida, the Operation Vaccinate Florida I & II (OVF) has been in operation since 2002. It focuses on the vaccination of the first responders such as paramedics, firefighters and police. The promotion was only partially successful because of the highly publicized adverse effects and deaths attributed of the vaccine. Two forms of smallpox exist: Variola major which is the most severe and common form of smallpox and carries a 30% case-fatal rate in an unvaccinated population, and Variola minor which historically carries a case-fatality rate of 1% or less. (38) It is less common and a much less severe disease. Sma llpox is considered to be at the top of the list of Categories A diseases because of its high mortality and morbid ity rates and its ease of transmission from human-to-human. For this reason, only Smallpox will be examined (Category A) for this study. If we are prepared against a smallpox attack, we should be able to respond to all other known biow eapons (“the all-hazards approach”).

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24 The smallpox ( Variola Major ) is acquired through the re spiratory track and spread throughout the body via the lymph n odes. There is a 7 to 17 da ys latent-incubation phase (average 12-14 days) and then a prodromal phase that normally lasts for 2 to 3 days. (39) During the prodromal phase, the subject norma lly presents flu-like symptoms such as severe headache, backache and high fever (40c +). Once this phase is complete, the lesions start to appear. The transmission from person to pers on is the greatest during the first 7 to 10 days of these lesi ons. (38) After 8 to 9 days, th e lesions begin to scab over. Unlike chickenpox, which is commonly confus ed with smallpox by the general public, the pox lesions are normally at the same stage of developmen t and are present mainly on the face, hands and ex tremities. (39) Death normally results from toxemia and superinfections. Patients that surv ive are severely scarred with pitted lesion and/or pox marks. Bioterrorism Preparedness Activities The very concept of public preparedness (also know as domestic preparedness) came into effect during the early years of the cold war when the Soviet Union successfully detonated its first atomic bomb. This resulted in the development of the Civil Defense Program and th e signing of the Civil Defe nse Act of 1950. The Civil Defense Act of 1950 had the policy and intent of the U.S. Congress to provide a civil defense system for th e protection of life and property of the United States from all attacks, including ones from natu ral disasters. This Act e ffectively made the protection of the civilian population a join t federal-state charge with the primary resp onsibility for civil defense residing in the state and local gover nment structures. Most of the basic principles of civil defense were developed du ring this timeframe and are still relevant to our current U.S. preparedness programs.

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25 Like the former civil defe nse programs, public health preparedness starts at the state and local levels. This concept is based on the fact th at the initial recognition and response to a biological attack will be at th e local level with support from the State. Local emergency managers and public health of ficials have a unique perspective of their communities. They understand the hazards and risks of a bi oterrorism attack to the community and the resources it has available to respond. Like all emergencies, once the local community needs exceed the local resource s, they will contact th e State, and if the State exceeds its resources, the Governor will make a formal request to the President. The President has the option to declare a federal emergency or just provide federal support. This process could take hours or days depend ant upon the urgency of the situation. The local emergenc y manager will continue to manage the incident within his/her community, even when it becomes a federally declared emergency and support from the state and federal government has arrived the scene. In addition, during a large s cale event such as a hurri cane or smallpox release, numerous communities may be competing for th e same state and federal resources (e.g. personnel and equipment). Since state and federal reso urces may not be immediately available to the local co mmunity, the local community (e.g. government agencies, hospitals, and utilities) must have an emergency operations plan (EOP) and a county mass casualty plan that can be act ivated with resources located within it boarders. In the case of a bioterrorism attack, the local community must have the ability to respond in a timely manner, since only a short window ex ists to provide vaccinations, prophylaxis and/or implement other counter measures. (40), (41) Thes e communities should drill and exercise these plans to identify shortfalls and to familiarize the personnel.

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26 Public health preparedness is crucial and should be perfo rmed at all levels of the public health care system. To enhance the capabilities of the federal, state and local bioterrorism preparedness levels, the CDC as part of its strategic plan implemented the Bioterrorism Preparedness and Response Program. This prog ram has five focus areas. They are 1) preparedness and prevention; 2) detection and surveillan ce; 3) laboratory; 4) response; and 5) communication. All five fo cus areas have training and research at it core. (42) These areas have been incorpor ated into the core public health workers bioterrorism competencies and are within the Florida Department of Health preparedness structure. The State of Florida, according to a report released in December 2003, made great improvements within its public health system since 2001. It was tied with California, Maryland and Tennessee as the most prepared states with in the nation, ach ieving 7 out of 10 preparedness indicators. (16) These indicators were based off the five focus areas set forth by the CDC (see ab ove). Of these 10 indicators, this research will focus on indicator 4, “Sufficient Workers to Distribute the National Stockpile Supplies.” While Florida received credit for succe ssful completion of this indi cator (16) because it has a strategic national stockpile pl an for most counties it is questionable wh ether the state has “sufficient” workers to distri bute the antibiotics and/or ad minister inoculations during large biological attack (s mallpox). The community heal thcare providers (“workers”) preparedness levels and willingness to re spond during the activation of the Strategic National Stockpile will be the focus of this research.

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27 The Strategic National Stockpile Congress tasked the Department of Hea lth and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC) with the creati on of the National Pharmaceutical Stockpile (NPS) in 1999. (43) The Strategic National Stockpile (SNS), as it is formally known today, is a national repository, the mission of which is to provide a re-supply of large quantities of pharmaceuti cals, medical supplies and equipment to be used in an event of national emergency within the United Stat es and its territories. This repository includes antibiotics antidotes to various chem icals, antitoxins, airway maintained and medical/surgical supplies that can be us ed to treat thousands of individuals during a crisis even t. Its primary purpose is to provide critical medications and medical supplies that woul d not otherwise be available to the affected community. (44) The decision to request the SNS assets are based on numerous factors, such as an overt release of a biol ogical agent that cannot be handle d by the State health department or outbreak surveillance warni ng signs of a possible large-s cale outbreak. Ei ther way, the governor’s office will need to formally re quest the SNS to be deployed. The final decision for SNS deployment is made by the Department of Homeland Security (DHS) and the Department of Health a nd Human Services (HHS). (43) The SNS deployment is designed to be deployed in two ph ases. The first phase is called the “12Hour Push Package”. These secure Plus Packages are strategically located throughout the Un ited States and can be deployed and be on location within 12 hours. (43) These locations ar e coordinated by each State and can be deployed to a designated hospital, Logist ic Staging Areas (LSA) or Point of Distribution (POD) location. These Push Packages have a broad spectrum of items, but are limited in the

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28 amount of each. The Push Packag e can be limited to the type of response needed. In the 2001 anthrax responses, only an tibiotics were deployed. The second phase is designed for a la rger scale event, where additional pharmaceutical and medical suppli es are needed. This phase utilizes the Vendor Managed Inventory (VMI) system. The VM I utilizes current pharmace utical supply changes and private transports such as UPS and Federal Ex press. The VMI will ship supplies that are tailored to the event type, if known. Thes e VMI shipments will be transported to the State LSA and should arrive within 24 to 36 hours. At the LSA, the supplies will be repacked from bulk pharmaceutical packaging to individualized doses, if necessary. Then they will be deployed to the PODs in the same manner as the Push Package. The Logistical Staging Areas (LSA) are normally placed around a State to effectively receive either th e Push Packages or the VMI shipments. The LSA normally needs to be located near an airp ort that can handle a large airc raft. The facility should be large enough to accommodate th e shipment of supplies. Th e LSA are kept confidential and are not open to the public. The public will be seen at the Point of Distribution (POD) Locations. Point of Distribution Centers The POD is used to triage and provide prophylaxis medi cations to individuals who were potently exposed and, if necessary, provide large scal e immunization of vaccines to the general population. The location and number of PODs during an event are dependant on the size of the population aff ected. Personnel requirements for the PODs within the State of Florida are calculated using th e Weill-Cornell Bioterro rism and Epidemic Outbreak Response Model (BERM).

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29 Bioterrorism and Ep idemic Outbreak Re sponse Model (BERM) Florida’s decision to use th e Weill-Cornell Bioterrorism and Epidemic Outbreak Response Model (BERM) as the centerpiece to determine the staffing needs to respond to a major disease outbreak and/or biological terrorist event on a specific population within the State may not have been the best choice It is not suggeste d that the model is incorrect, but that the model has been recomme nded by the Florida De partment of Health for use in developing county st rategic stockpile plans and mass casualty plans without determining the levels of preparedness a nd willingness to respond by community medical professionals not employed by the State. The Florida Department of Health, as the Essential Support Function #8 (E SF) State Representative fo r the Office of Emergency Management (OEM), has been tasked as the le ad agency in developi ng these plans by the Governor. The BERM model has been used by th e local health departments, county emergency operation centers (EOC), and stat e contractors throughout Florida to develop the core bioterrorism response plans even though the staffing le vels could not be fulfilled internally within the Florida Department of H ealth. This was discussed briefly in Chapter 1. Another example of this pr oblem is the Pasco County Health Department that serves a population of 388,908 permanent residents and has 212 employees with approximately 24% licensed medical profession als (physicians, nurses and de ntist). According to the BERM estimates, in a large-scale biological event Pasco County Hea lth Department would need 2,360 persons with 1,521 being core license d medical personnel fo r five consecutive days. This plan has a recogni zed shortfall of 2,148 total pers onnel with 1,469 in the core licensed medical personnel. The CDC is currently under consideration of reducing the

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30 required response time from 5 days to 2 days. If this becomes a requi rement of the SNS, the current estimate of personnel needed, will more than double. The BERM estimates and the working floor plans of the Points of Distribution center plans (POD) to dispense medications, even when adjusted, are requiring personnel levels over a one thousand percent (1000%) be yond what the county health departments have available during normal operations. Local hospitals will not be able to lend personnel to the health department because of local surge in demand for its services and the possibility of a dirt y hospital scenario. Other governme nt personnel such as teachers and transportation workers, even though not specified within cu rrent plans, could be used for non-core medical personnel positions. The only real solution is to use community healthcare providers to fill these planned positions. Community Healthcare Providers’ Preparedness The question that has been most frequen tly asked since the terrorist attack of 11 September 2001 is: “Are we ready or not?” Numerous studies ha ve taken place since 2001 on the United States’ abilit y to prevent and respond to fu ture terrorist attacks. These studies have mostly fo cused on conventional terrorist methods, such as various styles of bombings. The studies that did focus on biological ag ents or a bioterrorist attack have researched technology to identify an attack (samp ling methods and surveillance) and the methods to decontaminat e after an attack (processes and chemicals). There have only been a few studies that have directly focused on the preparedness levels of healthcare providers, and of these, most targeted only physicians.

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31 Roles of the Responding Healthcare Providers There are several roles of a healthcare provider, de pending of the providers licensing. As the plans and policies are currently written, during a bioterrorism attack only Florida licensed medical personnel can perform direct medical services. Credentialing of medical providers within Fl orida for such events is still under much debate. One must hope that me dical providers licensed in othe r states and/or retirees, will be allowed to treat patients during a Florida mass causality event. As of 01/2005, this option was not approved. There are numerous roles for a community physician related to a bioterrorism event. The first and foremost duty of a community physician is the early identification of individuals who have been expo sed to a bioterrorism attac k. The physician is ultimately responsible for the identificat ion and treatment of a biolog ical weapon exposure. Even so, in a nationwide survey, onl y 25 percent of family physicia ns felt prepared to respond to a bioterrorist event in 2001 (5) and again in 2002, only 21 percent of the physicians surveyed by the University of Chicago, felt personally well prepared for a bioterrorism attack. (45) All the studies to date rely on the self ev aluation of the physician to determine bioterrorism preparedness levels. Physicians responding to a bioterrorist attack will also provide the medical care to the patients as well as perform duties normally expected from the nurses such as pa tient triage and admi nistrating smallpox inoculations. In the United States, ther e are approximately 900,000 pr acticing emergency nurses (46), so it has been assumed that the larg est percent of licensed community healthcare providers to respond will be the nurses (RN, BSN). Nurses will also play a major role in recognition of potential bioterrori sm attacks. Nurses will serv e as the triage staff at the

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32 local Point-of-Distribution (POD) centers and hospitals. They will be also responsible for vaccinating the worried well and the expos ed during a terrorism attack. As in the Middle Ages, nurses will be the primary caret akers of the infected. While there have been several studies on the use of nurses volunteers in a biot errorism event and education standards in nursing programs, there was not a study that dir ectly addresses the perceived preparedness levels of nurses at the time of this study. Shortly after the 2001 attacks, National Ph armacist Response Teams (NPRTs) were formed. These teams are formed of pha rmacists, pharmacy students and pharmacy technicians. They are au thorized by Health and Huma n Services (HHS) to respond during a national emergency, such as a bioterrorism attack. There are currently ten teams nationwide. (47) Most bioterro rism plans, response teams an d surveillance systems in the State of Florida, while occas ionally monitoring over-the-count er medications for spikes, do not include th e pharmacist. Within this study, the pharmaci st is also included. It was felt that a pharmacist could be beneficial to Florida’s bioterrorism preparedness activities (other than the obvious dispensing of medications). Additio nally, pharmacist could potentially be the first to encounter an exposed patient in the community setting (drugstore). Persons who have been exposed are more lik ely to self treat (common co ld symptoms and rashes) in the early stages of the disease. This will give the trained ph armacist the ability to identify individuals whom may have been exposed. Pharmacists’ role s in a bioterrorism response range from clinical recogn ition, disease management, patie nt education (48), and from administration of the vaccines (PharmD. onl y) to the dispensing of the medications (R.Ph./PharmD.).

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33 There are other medical pers onnel that have clearly de fined roles or could be tapped into during a res ponse. The emergency medi cal technicians (EMT) and paramedics are the first respond ers and will probably be the first to begin to notice the increase in patient loads due to a bioterrorist attack. They wi ll also be the first of the healthcare providers to contract the di sease themselves. These responders will unfortunately be similar to a canary in the coal mines. Th eir exposure is like ly to signal a large bioterrorist event. While these types of providers are crucia l to a bioterrorism response, they were not included in this study. Previous Studies As stated earlier, previous study findings have demonstrated that the preparedness and infrastructure of the public health system are inadequate ly developed for a biological and/or chemical terrorism atta ck. (1),(2),(4);,(15). It wa s also found that those primary care providers that would have to respond to su ch an attack do not “feel” prepared to diagnose and manage such an event. (5) Th is came as no surprise to public health officials when these studies were first rele ased in 2001. Bioterrorism attacks were not considered as a real th reat in most areas prior to 2001. Even as recent as June 2004, local public health Directors in Fl orida has verbally dismissed the notion of a bioterrorism attack within their particular counties and have considered a large scale bioterrorism preparedness a misuse of the hea lth department resources. (49) Since these studies were or iginally published, the Publ ic Health Security and Bioterrorism Act of 2002 was passed. This provided the CDC with $915 million dollars to boost States and major metropolitan areas response capabilities. Then in early 2003, an additional $870 million was provided to the States by th e CDC. Other funding came

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34 from various federal agencies, such as H ealth and Human Services’ HRSA funding. HRSA funding provided another $622.5 million si nce 2002. This totals more than 2.4 billion dollars during fiscal years 2002 and 2003. (16) Of the 2.4 billion, Florida was awarded approximately $111 million dollars from the CDC and HHS for bioterrorism response. This is not al l inclusive for Flor ida’s bioterrorism funding sources. While all of the States re ceived funding, many are still unprepared. A recent study that examined 10 key indicators found that while most States have made some progress, most have fundamental structure problems that could threaten the United States’ ability to respond to a large-scale public health emergency. (16) Majo rity of the states (70%) received scores of 50% or below (5 or less i ndicators), which is indi cative of a successful national comprehensive bioterro rism response within the current public health system. These indicators include having a statewide bioterrorism plan, pr ovisions that no more than 3 counties are left without alert capabilities, passing of at least 50% of federal funds to the local health department s, and sufficient staffing to di stribute the Strategic National Stockpile (SNS). (16) Florid a is one of the four states that scored 70% (7 of 10 indicators). It was even sugge sted that the State had sufficient worker s to distribute the SNS. As explained earlier, the BERM estimates of licen sed medical personnel needed for an SNS response would i ndicate that Florida does not have the trained and willing workforce to successfully respond to an actua l large-scale bioterrorism incident.

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35 Bioterrorism Core Competencies The incorporation of emergency preparedness activities and their assessment is an expected part for the national public health system, individual public health practitioners and local public health depa rtments. While the use of the Standards of Practice (assessment) has been in place since 1923 for public h ealth services, the use of performance standards in the form of comp etencies have only ga ined acceptance in medical and public health professions in r ecent years.(22) In 1998, the CDC’s Public Health Practice Program Office (PHPPO), in conjunction with the public health practice community, developed performance standards for state and local agencies that are representative of the essent ial services for public healt h. With these completed and integrated within the pub lic health agencies, the next step was to focus on particular areas within public health practice. This is when the emergency preparedness standards (2000) were developed, which in turn evolved into the Emergency Response: Core Competencies for All Pu blic Health Workers first released in Ap ril 2001. Following the 2001 Anthrax Attacks, these competencies were reexamined and released as the Bioterrorism and Emergency Readiness: Compet encies for all Pub lic Health Workers in 2003. (22) Selection of the Core Co mpetencies for this Study The Public Health Workers’ Emergency Preparedness Core Competencies for Emergency Response and Biot errorism, which were developed by the Columbia University School of Nursing, Center for Health Policy, and the Emergency Response Clinician Competencies in Initial Assessment and Management, developed by the Association of Teachers of Preventive Medicine in collab oration with Center for Health

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36 Policy, Columbia University School of Nurs ing and 17 national asso ciations, including the American Medical Associ ation (AMA), were used in the development of the conceptual framework for th is study. These projects were supported by the Center for Disease Control (CDC) and/or Prevention/ Association of Teachers of Preventive Medicine Cooperative Agreement to insure the readiness of h ealthcare workers’ ability to perform in emergency and biot errorism situations. (22) The researcher chose these competency sets as the base template for the determination of the biote rrorism competency level (B CL) because of its current integration into Florida’s public health care system and beca use it is the recognized set by the Center of Disease Contro l (CDC). (22) Additionall y, after reviewing numerous strategic national stockpile and mass ca usality plans for Florida’s county health departments the researcher believes that during an actual bioterrorism response, community health care providers would need to be integrat ed within Florida’s public health care system. If this is done, community health care pr oviders would be required to work within the constraints of the Florida public health syst em and would need to have the same levels of competency as the Depa rtment of Health empl oyees when responding to the event. Upon the recommendation of th e lead developer of the or iginal competency sets, the individual competencies were used as the guiding template only and were not directly transplanted without adjustme nts to measure preparedness levels within this given population, and the duplications between the two competency sets were removed. (50) These modifications were developed thr ough direct communications with emergency preparedness designated employees within the Florida Department of Health and

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37 preparedness experts throughout the United St ates (see Table 2-1) Once this was completed, a method of measuri ng the competency levels wi thin community healthcare providers also had to be deve loped for this study. This is discussed in Chapter 3 under Research Instrument: Phas es of Development. Table 2-1 The Core Competency List as modifi ed by experts for this study. ADMINISTRATIVE COMPENTCIES (AC) Administrative Competency 1. Describe the role of your workplace in an emergency response. Administrative Competency 2. Identify the chain of comma nd in emergency response. Administrative Competency 3. Identify and locate the agency ’s emergency management plan. Administrative Competency 4. Describe his/her functional role(s) in emergency response and participate in these role (s) during regular drills. Administrative Competency 5. Demonstrate the correct use of communication equipment used for emergency communication. (phone, fax, radio, satellite phone) Administrative Competency 6. Ability to locate th e communication role(s) in emergency response plan and understand his/her role. Administrative Competency 7. Identify limits to own knowledg e, skill, and authority, and identify key system resources for refe rring matters that ex ceed these limits. Administrative Competency 8. Demonstrate creative problem so lving and flexible thinking to unusual challenges within his/her functional responsibilities to res pond to a bioterrorism event. CLINICIAN COMPETENCIES (CC) Clinical Competency 1. Describe his/her expected clinical role in bioterrorism response for the specific practice setting as a part of the institution or community response. Clinical Competency 2. Respond to an emergency within th e emergency management system of his/her practice, in stitution and community. Clinical Competency 3. Recognize an illness or injury as potentially resulting from exposure to a biological, chemical or ra diological agent possibly associat ed with a terrorist event. Clinical Competency 4. Ability to report identified cases or events to the public health authorities to facilitate survei llance and investigation using the established institutional or local communication protocol. Clinical Competency 5. Initiate patient care with in his/her professional scope of practice and arrange for prompt referral appropria te to the identi fied condition(s). Clinical Competency 6. Communicate risks and actions ta ken to patients and concerned others clearly and accurately. Clinical Competency 7. Recognize and manage the psycholo gical impact of a Bioterrorism event on victims and health care professionals, as appropriate to the event. Clinical Competency 8. Recognize unusual events that mi ght indicate an emergency and describe appropriate action

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38 Rationale and Conceptual Framework The purpose of this study is to id entify healthcare providers’ level of preparedness, and to determine factors that predict the community healthcare providers’ clinical and administrative competency to ma nage a bioterrorism at tack and to predict their willingness to re sponse to a biological te rrorism attack within the State of Florida. Various recognized sets of core competen cy sets (see appendix B.) for emergency preparedness were combined to form the Conceptual Framework for this study. Figure 2-1. Conceptual Fr amework of the Study.

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39 Conceptual Framework of the Study The conceptual framework mode l (see Figure 2-1) for this study suggests that three domains should be used to determine th e preparedness levels of the community healthcare providers. The first domain is th e willingness to respond to a bioterrorism attack, domain two describes administrative competencies, and domain three describes clinical competencies. The first domain examined whether the provider was wi lling to respond to a high risk event and to a low risk event, and at wh at distance (proximity) from the normal work place (local event, regional event, state event, national event). This domain used a modified interpretation of th e Theory of Reasoned Acti on (TRA) to help model an individual’s willingness to respond levels. According to TRA the most important determinant of his/her behavi or is a person’s behavioral intention, in this case, willingness to respond. (51;52) The direct dete rminants of an individual’s behavioral intention (willingness) are hi s attitudes toward performing the behavior (responding) and his subjective norm (perceived beli ef of professionals) associat ed with that behavior. (53) TRA has the underlying assumpti on that all individuals are rational actors (i.e. all individuals’ process informati on and are motivated to act on it). The st rength of the TRA is that it provides this study a framework for discerni ng the reasons that motivate individuals to perform a behavi or. (52) In the ca se of this study, we looked at the behavioral intentions in th e issues of perceived thre ats/benefits for responding (community/family tiesproxi mity), the perceived commun ity’s/personal ability to successfully respond and the perceived level of risk to the responders with various demographic factors. This allowed the researcher to understand the factors associated with healthcare providers’ willingness to re spond and to hypothesi ze the specific reasons

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40 that can motivate the behavior of interest. While TRA has not been directly used to explain the willingness to respond in an emerge ncy (i.e., hurricane, bioterrorism), it has been used in predicting and explaining a wide range of health behaviors. These behaviors include clinical breast exams, contraceptive use, drinking, mammography use, smoking, seat belt use, and safety helmet use. (54) Figure 2-2: Predictive Model of the Theory of Planned Beha vior. Source: Based on Ajen. (55) The second domain examined the administrative competen cy of the healthcare provider. It was developed using Public Health Workers’ Emergency Preparedness Core Competencies for Emergency Response and Biote rrorism. These were used to determine: the providers’ ability to know the role of their workplace in an emergency response; the providers’ knowledge of their chain of command in emergency response; their ability to identify and locate the agency emergency re sponse plan; knowledge of his/her functional

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41 role(s) in emergency response a nd participation in these role (s) during regular drills; the providers competency level in the correct use of communication equipment used for emergency communication; the providers’ abil ity to locate the comm unication role(s) in emergency response plan and understand his/he r role; the providers’ ability to identify limits to own knowledge, skill, and authorit y, and identify key sy stem resources for referring matters that exceed these limits; and the ability to creative ly solve problems and use flexible thinking for unusual challenges wi thin his/her functional responsibilities to respond to a bioterrorism event. The third domain examined the clinical competency le vels of the healthcare providers. This domain was shaped us ing the Emergency Response Clinician Competencies in Initial Assessment and Management. These competencies examined: the providers’ ability to know his/her expected clinical role in the bioterrorism response for the specific practice setting as a part of the institution or community response; ability to respond to an emergency event wi thin the emergency management system of his/her practice, institution and community ; ability to recognize an illness or injury as potentially resulting from exposure to a bi ologic, chemical or radiologi cal agent possibl y associated with a terrorist even t; ability to report identified cases or even ts to the public health system; ability to f acilitate surveill ance and investigation using the established institutional or local communi cation protocol, and initiate patient care within his/her professional scope of practice and arrange for prompt referral appropriate to the identified condition(s); ability to communicate risks and actions taken clearly and accurately to patients and concerned others; ability to rec ognize and treat the psyc hological impact of a bioterrorism event on victims a nd health care professionals as appropriate to the event;

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42 and the ability to rec ognize unusual events th at might indicate an em ergency and describe appropriate actions. In addition to the three doma ins, the researcher examined the provider’s individual demographics such as age, gender, race, highest educatio nal degree, years worked as licensed professional, curren t position, employment status, and work duties. It also examined the workplace demographics such as workplace zip code, patient encounter volume, city type, population size, workplace type and the existence of a disaster plan at the workplace.. Perceived benefits and thr eats were used to examine the providers’ beliefs regarding the benefits of prepared ness training, whether hi s/her community were at real risk of a bioterrorism attack, and whether they had th e ability to respond to such an event. Finally, the different types of training methods and their ab ility to affect the overall preparedness levels of health care providers were examined. The training types used in this study are grouped as: (1) traditional lecture format (i.e., slides, handouts, videos, etc.); (2) online interactive (i .e., discussion boards, tutorial s, simulations, etc); (3) webcasts, teleconferences, or satellite broadcasts and; (4) self learn, self paced study (i.e., independent study courses).

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43 Data Collection Tools: a comparison amon g Web-based, e-mail, and traditional mail survey Traditional mail surveys have been used as a major data collecti on method in health professionals for thei r current knowledge, pract ice patterns, and attitudes of providing healthcare services. Recently, email and Internet surveys became valid alternative data collection tools to traditional mail survey si nce researchers were allowed access to the Internet in early 1980s. (56-58) The early phases of email ba sed surveys, the qu estionnaires were constructed using simple text (ASCII) and embedded in the body of an email and sent via Internet. (59;60) These email questionnaires had similar characteri stics as paper survey s in respect of the format of the questions and its length limitation, except th e email surveys obviously took shorter time to deliver to the recipients as compared to the trad itional mail surveys. When the Internet became mo re widely accessed, web based surveys was introduced for data collection in early to mid 1990s in supplement to the ema il survey and even sometimes administrated solely in the that method. In general, web based surveys had the ability to offer multimedi a applications including audi o, pictures, and video, which significantly improv e the user interface with these interactive features. The benefits and limitations of email based and web ba sed surveys, comparing to traditional mail surveys, are still under de bate. While several studies on email and traditional mail surveys suggest that email surveys have potential benefits over the traditional mail surveys by decreasing time of delivery and response, and cost (59;60), other studies found that email and web surveys have significa ntly lower response rates. (61-67) Since this study appl ied a dual mode survey method using an email to introduce the research study and to provide a link to a web based survey, literature regarding an

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44 email and a web based survey of health professionals are di scussed in comparison to the traditional mail survey. This section discusses the issues regarding survey te chniques, sample coverage, response rate, cost, time to response, and pos sible errors of web, email and traditional mail survey methods. Compar isons of advantages and disa dvantages of these survey methods are described ba sed on literature. Survey Techniques There are several advantages of a web based survey over ma il survey, if the optimal web-survey software is applied. First, the questions can be programmed to automatically input the data into the desire d format. Transcription errors during data entry are eliminated. Second, logical check for the answers is possible by programming the order of the questionnaire items. Third, web surveys allow real-time monitoring of the respondents and automatically send a follow-up message to the lists of nonrespondents in a timely ma nner. Fourth, web surveys overcome one of the major limitations of traditional mail survey by automatically skippi ng the questions that are not applied to a certain population. This technique is called “ski p pattern automation”. By using this technique, the length of the qu estionnaires and time to complete could be greatly reduced. A study by Jepson et al. 2005 found that a negative association between the length of the questionnaire s and response rates, and the completeness of the returned surveys. (68)

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45 Survey Population Coverage and External Validity For the traditional mail survey, the st udy population is well defined, then samples are selected by either convenient sample or a random sampling methods Then a letter of invitation and an informed c onsent form are sent by postage mail with or without the questionnaires. Email surveys apply similar methods of selecting a study sample. (69;70) Several email survey studies have select ed samples from members who have email address registered with professional as sociations, e.g., the American Urological Association (57), the College of Family Physicians of Cana da (71), the Association of Cardiothoracic Anesthetists. ( 56) The limitations of the email surveys regarding the representation of the population is that characteristics of people who have email addresses may be different from people who di d not have an email address and thus, are not included in the study. Email addresses might not be updated. The samples may not receive the questionnaire survey due to th e spam e-mail blocking software. From the above limitations, email survey f aces challenges that may compro mise external validity. For the email combined with a web based survey, the same li mitation of population coverage and external validity applied. Howe ver, for web based surv ey alone it offers benefits in allowing unlimited access by any pa rticipant who volunteer to complete the survey. Several studies recruited participan ts from advertising in newsgroups, specific web pages, or in newspapers which obtained convenient sa mples. From this method, there is no defined population and thus response rate cannot be calculated with this particular recruitment method for web-surveys.

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46 Response rates Response rates of e-mail surveys vary ba sed on the content of the survey and the populations. A review by Chonlau et al. su mmarizes response rates of the Internet surveys in 31 studies. (72) Web surveys obtained 7 to 44% response rates compared with 6 to 68% for email surveys. The author summarizes that the response rates of email and web surveys are usually lower th an traditional mail survey. However, using a web survey to supplement email survey s hows an improvement response rates. Examples of two studies of attitudes of phys icians toward healthcare serv ices using email and/or web survey found relatively high re sponse rates. Kedall and hi s colleagues conducted e-mail survey on infection control fo r adult cardiac surger y. The response rate was 81% (29/36 units). (56) A study of attitu des of urogynecology and maternal -fetal medicine specialists toward primary elective cesarean delivery wa s conducted using email attached with web based survey. Response rate after an ini tial email and two follow-up emails after one month was 52.9%. (70) A study of online resource ut ilization (Internet and em ail) of Scottish general practitioners found that small number of GPs using internet or email to communicate with their colleagues and pa tients (21%, 13%, and 4% resp ectively). Younger GPs were more likely to use the Internet. The results of this study suggest th at web based or email survey modes may be more suitable fo r surveying younger pract itioners.(58) Time of Delivery and Response Seguin conducted a clinical trial in 2004 comparing response rate and time between email and traditional mail su rvey methods among Canadian family physicians.(71) The study f ound that the response rate of a traditional survey is

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47 significantly higher than an email survey (52.7% vs 33.6%). However, delivery and response time of the email surv ey was much faster than th e mail survey. Completeness of the content was not differ ent between the two methods, but the email survey contained longer and more frequent co mments. The authors concluded that email survey is appropriate method when quick response is required.(71) Cost Costs of web or email surveys compared with mail surveys are not still understudied. According to the existing literature, costs vari ed depending on the types of survey, numbers of mail-outs or number of completed responses, and the implemented technology. For the web survey, most costs we re associated with personnel who design and test the survey. Marginal personnel costs are almost al ways significantly greater than other marginal survey cost, e.g., paper, printing, and postage. A study by Couper and his colle agues showed no significant cost benef it of e-mail survey compared with tradit ional mail survey. (61) The cost in constructing e-mail surveys included the bui lding and evaluating e-mail softwa re which required more than 150 hours and approximately cost $1.74 per comp leted case, while th e cost of postagemail was $1.81 per reply. In addition, in most cases email surveys require technical support, e.g., toll-free calls that add more cost of this method which seemed to offset any potential savings. The study from Schleyer and Forrest co mparing cost of web and mail survey methods found that web survey cost 38% less than mail su rvey for 22-item questionnaires.(61) However, the benefit depends on the number of respondents. If there are more than 347 respondents; web survey o ffers cost-saving. On the other hand, if the

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48 number of respondents is less than 189, mail survey is preferab le. It is not a conclusive choice of method, if the responden ts are between 189 and 347. Other two studies concluded that email and web surveys are less expensive than mail surveys, when cost of personnel was excluded. The re sults of the study in the UK indicated that email alone, a nd email and web cost less than mail surveys (35 pence, 41 pence, and 92 pence per reply, respectively). (62) The authors referred to the cost saving simply from eliminating cost of paper, printing, and postage. Data Quality Data quality is defined by the percenta ge of the responden ts who have missing data at least one survey item or the percentage of the mi ssing items per questionnaires. Literature suggests that traditional mail surv ey had significantly smaller percentage of missing items comparing with e-mail survey (0.3-0.8% vs. 0.33.7%). (61), ;(64), (73-75) Data quality based on the percentage of respondents who missed at least one questionnaire item is controvers ial. Paolo et al. found that ma il survey had lower rate of incomplete returned questi onnaires compared with e-ma il survey, 27% vs. 9%. (75), while Kiesler and Sproull f ound the opposite results (10% vs. 22%). (76) Two other studies by Tse et al. found no si gnificant different in the per cent of incomplete responded questionnaires. (67), (77)

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49 ‘We’ll never use the damn germs… If someone uses germs on us, we’ll nuke ’em. ’ President Richard Nixon, 1969

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50 CHAPTER 3 RESEARCH METHODOLOGY This study was motivated by the recognized threat of weap onized biological agents being released upon Florida’s population and th e uncertainty that Florida’s community healthcare providers have the necessary compet ency levels and the willingness to respond to a bioterrorism attack w ithin the State of Florida. Understanding the current competency levels of Florida’s community healthcare providers and their willingness to respond is crucial to the ability of the State of Fl orida to activate cu rrent bioterrorism plans. The current plans re ly on large numbers of licens ed healthcare providers to diagnosis and treat patients. The numbers currently re quired by these plans greatly exceed the number employed by the state government system, thus requiring licensed healthcare providers from the comm unity to fill these roles. Study Design and Methodology The design of this study re lied on the development of a conceptual framework that was based on the public health bioterrori sm core competencies (see Chapter 2: Bioterrorism Core Competenci es), and the design and implem entation of a descriptive, cross-sectional survey to evaluate the level of bioterrorism prepared ness of the healthcare providers in Florida. The study also examine numerous f actors that are related to preparedness levels, such as individual a nd workplace demographics, perceived benefits

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51 and threats, and methods and modalities of trainings. Th ese factors, along with the “willingness to respond”, were examined from the point of view of their relationship to the preparedness levels of he althcare providers as a whole and between the professional groups. The primary aims of this study was: 1) to give insight into Florida’s community healthcare providers’ clinical and administrative competencies to manage a bioterrorism attack, 2) give an insight into their willingness to response to a biologic al terrorism attack within the State of Florida, and 3) assess the current leve l of preparedness of Florida’s community health care providers (physicians, pharmacists and nurse s) to identify and manage a biological terrorism attack. The study also attemp ted to verify in Florida’s population of healthcare providers the 2002 st udy findings suggesti ng that 75% of the U.S. physicians do not "Feel" prepared to id entify and manage a biological terrorism attack. (5) Survey Sample The population under study is all Florida licensed nurses, pharmacists and doctors. The only inclusion crite ria are to have an active license in the State of Florida (population boundary), and reside in the Stat e of Florida a porti on of the year (ge ographic boundary). These particular professions were chosen becau se of their legal ability to either give and/or dispense medications/immunizations to humans in the State of Florida. In a suspected biological terrorism a ttack, a large percentage of th e health services provided are triaging and treatment by physicians and nurses, and th e dispensing of antibiotic medications (pharmacists) and/or giving inoc ulations of the “Wo rried Well” population by all three professions.

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52 A list of emails for Florida’s licensed nurses, pharmacists and physicians were retrieved from the State Board of each health pr ofession and/or its professional association. These emails were selected fo r their convenience and the li mited availability of funding resources to mail paper surveys. A total of 42,000 emails were able to be retrieved for this study. These emails were checked for duplication a nd visual accuracy (i.e. Name@Companyname.Com). Duplicated emails were deleted and emai ls that had obvious errors (i.e. Name@Companyname.c a n), were corrected. All unc orrectable emails were removed from the list. A non-probability sampling technique was used for this study. By the fact that the emails were requested from different profes sional groups, quota sa mpling was used to obtain the required population propor tions for each of th e healthcare prof essions. A total of 34,482 (16,807 Physicians, 2,807 Pharmacist s, and 14,868 Nurses) emails that presented no visual errors were obtained. A large proporti on of these email addresses were 18 months or older. Sample Calculations Sample sizes were calculated based on 5% error rate, 95% co nfidence interval. There were 274,653 primary care physicians 20,760 full-time ph armacists and 170,000 nurses licensed in Florida in 2004. The sample size requirement wa s 384 respondents for the physician grouping, 377 respondents for the pharmacist grouping, and 383 respondents for the nurse gr ouping. A 5% response rate was approximated, thus the researcher had to email a minimum of 7,600 qu estionnaire invitations to each healthcare profession. A minimum of 22,800 total questionnai re invitations were sent to reach the required sample size. Even t hough response rates for similar st udies have been as high as

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53 x 100 65% (5), it was decided to use a 5% response rate. This wa s due to the f act that the population of Florida previously had four major hurricanes and there could have been Internet connection outages a nd/or persons relocating to ot her states while their homes were being repaired. The survey was mana ged completely via th e world-wide web, and large percentage of provider em ails collected for this study were 18 months or older. The average attrition rate of opt-in email addresses were 6 to 8% per month.(78) Estimating that the email mean age is 8 months, the total ema il attrition rates could range between 48% (16,551) to 64% (22,0 68). The attrition rates we re calculated using custom design server based logging software. Ev en though the email co uld produce numerous return emails explaining the email was bad or blocked, the softwa re could determine unique returns, filtering duplicates. The response rate (RR) was calculated as the surveys were completed, divided by the number of emails sent, minus the boun ced /blocked emails due to attrition. Response Rate = Surveys Completed Total Emails Sent – Bounced Emails Letters of Invitation Letters of invitation to partic ipate in this study were sent out via email to healthcare providers. The healthcare provider opted into the study by visiting the designated website listed in the email and agreed to complete the questionnaire. The letter and the referring website outlines the subject’s right to confidentiality and the anonymity of the data.

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54 This letter was sent out maximum three times to all participants. Since no identifying information was collected during the survey, there was not a way of tracking which participant completed the survey, t hus having to perform follow-ups with all participants. Once the needed sample size was accomplished, no further email reminders were sent out. Research Instrument The questionnaire was offered completely online at the website Questionpro.com and consisted of 59 questions pr esented in an attractive, br ief and easy to respond format (see questionnaire in A ppendix A.). While this survey recruited participants via email, this survey is considered a World Wide Web (WWW) survey since the data was collected via a website and not by return emails. The survey was structur ed to reflect the ob jectives of the stu dy, while at the same time not asking leading questions The survey utilized elect ronic branching, which varied the length of the survey depe nding on the answer applied to the previous question, and asked mostly closed questions to improv e the response rates of the participants. Phases of Development The survey instrument was developed in several phases. First, personal communications with known ex perts and the examination re levant literature were conducted to determine a met hod to measure Florida’s comm unity health care providers’ “bioterrorism preparedness” level. Sec ond, the conceptual frame work was developed (see Figure 2-1.) based on th e information retrieved.

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55 Third, a group of experts was asked to examine the study framework and the competencies used to measure the providers’ bioterrorism competency levels (BCL) for correctness. The group assigned weights to each of the administrative and clinical competencies, and weighted th e competency groups according to importance, using their expert knowledge and experience with th e core competencies and emergency preparedness (see Figure 3-1) This expert group included such members as the public health core bioterrorism and emergenc y competencies’ developer from Columbia University, Dr. Kristine Gebbie; the current Chie f of Staff of the Offi ce of Public Health Emergency Preparedness at Health and Human Services (HHS); the former Director of Navy Medicine, Office of Homeland Security; th e Duty Director of the Global Center for Disaster Management and Humani tarian Action at the Univers ity of South Florida, along with preparedness experts em ployed by the State of Florida, partic ularly the Florida Department of Health. Thes e experts were chosen either because of their years of leadership experience in emergency planni ng and response, and/or their in-depth knowledge of bioterro rism and the core competencies. Fourth, other surveys and, when available, their results were ex amined from across the country. It was decided to include a few of the same qu estions that were presented across the spectrum of surveys for future population co mparability. Since a survey instrument did not exist, the questionnaire had to be develo ped specifically for this study. The survey’s questions were develo ped to capture the necessary data. Fifth, content and face validity of the res earch instrument was conducted. Face validity was conducted by a cursory review by fellow re searchers, students and coworkers at the University of South Florid a and the University of Florida. Content

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56 validity was assessed by experts in the Florid a Department of Healt h, the University of Florida and other government agencies. In addition, que stions 46 through 49 were verified that those questions were able to correctly test a basic level of bioterrorism preparedness knowledge of the subjects. To examine these par ticular questions, 30 participants were separated in two subgroups of 15, novice and advanced. The advanced subgroup was known to have the basic knowle dge on bioterrorism and preparedness, while the novice subgroup was known not to have any knowle dge of the subject. Each subgroup included healthcare providers from each profession. The advanced group answered all the questions correctly, while th e novice subgroup only answered 25% correct. The results confirmed that the questions had the ability to correctly determine whether the subject had basic knowle dge of bioterrorism or not. Sixth, a pilot study was conduct ed to test the research instrument for internal validity and errors. The internal validity or reliability (correlation between the questions) of the questionnaire for the questions regarding the prepar edness level to bioterrorism attack was tested using Guttman Split-ha lf approach, Cronbac h’s alpha = .8109. The Cronbach’s alpha coefficient is greater than 0.65, which indi cates that the questionnaire has high reliability. (79) Demographic questi ons were not tested fo r reliability. Finally, the email invitation will be em ailed out and data collected.

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57 Figure 3-1. Weighted Competency Values Data Collection The letter of invitation was se nt via email to all subject participants. The survey was opened on a Sunday night and ran for 7 days. Reminder emai ls were sent out on days 3 and 7. The subjects who chose to opt into the survey followed a unique link to the website hosting the questionnaire and colle cting the data. This unique link assigned by the survey software prohibits the same person from taking the survey more than once. Once the participant arrived at the website, he/she r eceived additional information about the survey a nd was given the option to “con tinue” the questi onnaire. The questionnaire only asked one question at a time and did not allow the return to the previous question, or to save and return at a later date. Once the questionnaire was completed, the participant was directed back to the University of S outh Florida, College of Public Health website.

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58 The website was password protected and encr ypted for data security. The data was kept in a database on the serv er until the survey was close d. Once closed, the data was retrieved in both a comma-delimited format and in a Microsoft Excel formatted file. Once the data was successfully retrieved, the survey and the data were permanently removed from the server. Data Preparation The data, once collected from the server, wa s visually inspected for quality control. SPSS, version 11.5 (80) was selected as the pr eferred statistical software program to conduct the analysis. Measurements Demographic char acteristics of the Florida hea lthcare providers were collected using 15 questions. Th ere are two types of characteristics: indivi dual and workplace characteristics that are potentially associated with the bioterrorism preparedness level. Individual’s characteristics include: age, ge nder, race, highest edu cational degree, years worked as licensed profession al, current position, employmen t status, and work duties. Workplace characteristics are zi p code, patient encounter volume, city type, population size, and workplace type. Thes e demographic variables were tested for the prediction of the preparedness level using a logistic regression model.

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59 Figure 3-2. “Willingness to Respond”Example Proxi mity of the Events Willingness to Response Willingness to respond within Florida was assessed in six situ ations based on the proximity of the events (local regional, and statewide, see Figure 3-2) and the level of personal risks to the healthcar e providers (low risk and high risk). The question used a 5point Likert Scale to measure th e level of willingness to resp ond (1-5, very likely to very unlikely). The score was calculated in each situation as one (willing to respond), if the subjects choose “very likely” or “somewhat lik ely”, and zero (not w illing to respond), if the subjects choose “neither likely or unlikely” or “Somewhat unlikely” or “Very unlikely”.

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60 Willingness to Respond in their Lo cal Community (with in the county) The healthcare provider willingness le vel in the providers’ local community (HCPWLlocal) was calculated based on two survey questions (ques tions 50 and 54) addressing the willingness to respond to a hi gh risk event and a low risk event in their local community. HCPWLlocal = (WRhr_local + WRlr_local) 2 HCPWLlocal: Mean score of the healthcare provider willingness level in the providers’ local community WRhr_local: Willingness to respond score with high risk to provider’s safety in a local community response WRlr_local: Willingness to respond score with lo w risk to provider’s safety in a local community response Willingness to Respond within the Region (surro unding counties) The healthcare provider willingness to respond level within the region (HCPWLregion) was calculated based on two survey questions (questions 51 and 55) addressing the willingness to respond to a high risk event and a low ri sk event within the surrounding counties. HCPWLregion = (WR hr_rg + WR lr_rg ) 2 HCPWLregion: Mean score of the healthcare provi der willingness level within the counties surrounding th e local community

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61 WRhr_rg: Willingness to respond score with high risk to provider’s safety to bioterrorism events within th e counties surround ing the local community WRlr_rg: Willingness to respond score with low risk to provider’s safety to bioterrorism events region within the counties su rrounding the local community Willingness to Respond with in the State of Florida The healthcare provider willingness to re spond level within the State of Florida (HCPWLstatewide) was calculated based on two survey questions (question 52 and 56) addressing the willingness to respond to a high risk event and a low ri sk event within the State of Florida. HCPWLStatewide = (WR hr_statewide + WR lr_statewide ) 2 HCPWLstatewide: Mean score of the healthcare provi der willingness level within the State of Florida WRhr_statewide: Willingness to respond score with high risk to provider’s safety to bioterrorism events with in the State of Florida WRlr_statewide: Willingness to respond score with low risk to provider’s safety to bioterrorism events region within the State of Florida Willingness to Respond w ithin the United States The subjects were asked about their willingn ess to respond at the U.S. level (at high risk and low risk situations). This assessm ent provided additional information of whether Florida healthcare providers were willing to respond to the events outside Florida. The

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62 healthcare provider willingness to respond level within the Un ited States (HCPWLusa) was calculated based on two survey questi ons (questions 53 a nd 57) addressing the willingness to respond to a high risk event and a low risk event within the United States. HCPWLusa = (WR hr_usa + WR lr_usa ) 2 HCPWLusa: Mean score of the healthcare provi der willingness level within the United States WRhr_usa: Willingness to respond score with high risk to provider’s safety to bioterrorism events within the United States WRlr_usa: Willingness to respond score with low risk to provider’s safety to bioterrorism events region within the United States Administrative Competency Level (ACL) The administrative competency level was measured in two terms: 1) the mean percentage of the sample population who ar e competent (number of subjects who are competent in each competency divided by tota l number of subjects), e.g., on average 80% of subjects are competent in the administrative core competencies, and 2) the mean percentage of the individuals’ competency le vel (number of competencies possessed by a subject divided by eight), e.g., on average th e subjects are compet ent in 70% of the overall core administrative competencies. ACL was calculated by the weighted average of each of the eight administrative core competencies (see Figure 3-1). Eight experts assigned the weight to each competency based on a total we ight of 100% divided between the eight competencies. If the competencies are equally important the weight is 12.5%. The mean weight of each

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63 competency was calculated from all assigned weights from the experts. This mean weight was used in the calculati on of the ACL of the sample. ACL = (0.103*AC1) + (0.126*AC2) + (0.103*AC3) + (0.159*AC4) + (0.153*AC5) + (0.062*AC6) + (0.103*AC7) + (0.191*AC8) Note: The descriptions of AC1-8 are described below. Administrative Competency 1 (AC1) AC1: Describe the role of your work place in an emergency response. The AC1 was demonstrated in one question (question 37). If the subject knew their workplace’s role in a suspected bioterrorism attack (“Str ongly Agree” or “Agree”), the value of one was assigned to this variable. If the subject did no t know their workplace’s role in a suspected bioterro rism attack (“Neither Agree nor Disagree”, “Disagree” or “Strongly Disagree”), the value of zero was assigned. Administrative Competency 2 (AC2) AC2: Identify the chain of comm and in emergency response. The AC2 was demonstrated in one question (question 36). If the subject knew their chain of command in a suspecte d bioterrorism attack (“Stro ngly Agree” or “Agree”), the value of one was assigned to this variable If the subject did not know the chain of command in a suspected bioterrorism attack (“Neither Agree nor Disagree”, “Disagree” or “Strongly Disagree”), the va lue of zero was assigned.

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64 Administrative Competency 3 (AC3) AC3: Identify and locate the agency’s emergency management plan. The AC3 variable was demonstrated using tw o questions. If the subject knew if the organization had an emergency response or disaster plan (q uestion 13, answer of “Yes”), a value of one was assigned to variable AC3Ident and if the subject knew where the plan was located (question 14, answ er of “Yes”), the value of 1was assigned to variable AC3Locate. The variable called AC3 was assign ed a score of on e, if both AC3Ident and AC3Locate had a score of one If either AC3Ident or AC3Locate had a value of zero, a zero was assigned to AC3. If th e subject did not know if the organization had an emergency response or disaster plan (question 13, answer of “NO” or “I do not know”), the value of zero was assigned to AC3. Administrative Competency 4 (AC4) AC4: Describe his/her functional role(s) in emergency response and participate in these role(s) during regular drills. The AC4 variable was demonstrated usi ng two questions. If the subject knew his/her functional role in an emergency response (ques tion 35, answer of “Strongly Agree” or “Agree”), a value of one was assigned to variable AC4Role and if the subject had participated in a disaster drill (question 21, answer of “Yes”), the value of one was assigned to variable AC3Part. The variable called AC3 was assigned a score of one, if both AC3Role and AC3Part had a score of on e. If either AC3Role or AC3Part have a value of zero, a zero was assigned to AC 3. If the subject did not kno w his/her functional role in an emergency response (question 35, answer of “Neither Agree or Disagree”, “Disagree,

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65 or “Strongly Disagree”) or if the subject had no t participated in a di saster drill (question 21, answer of “No”), the value of zero was assigned to AC3. Administrative Competency 5 (AC5) AC5: Demonstrate the correct us e of communication equipment used for emergency communication. (phone, fax, radio, satellite phone) The AC5 was demonstrated in one question (question 20). If the subject knew how to use three of four comm unication methods (each of th e following marked “True”: Phone, Fax, Radio or Satellite P hone), the value of on e was assigned to this variable. If the subject did not know how to use three of four communication me thods (each of the following not marked: Phone, Fax, Radio or Satellite Phone), th e value of zero was assigned to AC5. Administrative Competency 6 (AC6) AC6: Ability to locate the co mmunication role(s) in the emergency response plan and understand his/her role. The AC6 variable was demonstrated usi ng two questions. If the subject knew whom to call to report/refer a suspected bi oterrorism attack (q uestion 38, answer of “Strongly Agree” or “Agree”), a value of one was assigned to variable AC6Refer and if the subject knew if the emergenc y plan addressed communicati ons (question 19, answer of “Yes”), the value of one was assigned to variable AC6Plan. The variable called AC6 was assigned a score of one, if both AC6Refer and AC6Plan had a score of one. If either AC6Refer or AC6Plan had a value of zero, a zero was assigned to AC6. If the subject did not know whom to call to report/refer a su spected bioterrorism attack (question 38,

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66 answer of “Neither Agree or Disagree”, “Disagree, or “Str ongly Disagree”) or if the subject did not know if the emergency pl an addressed communications (question 19, answer of “No”), the value of zero was assigned to AC6. Administrative Competency 7 (AC7) AC7: Identify limits to own know ledge, skill, and authority, and identify key system resources for referring matt ers that exceed these limits. The AC7 was demonstrated in one question (question 40). If the subject knew their limits in knowledge, skill and authority in a suspected bioterrori sm attack (“Strongly Agree” or “Agree”), the value of one was assigned to this variable. If the subject did not know their limits in knowledge, skill and aut hority in a suspected bioterrorism attack (“Neither Agree nor Disagree”, “Disagree” or “Strongly Disagree”), the value of zero was assigned TO AC7. Administrative Competency 8 (AC8) AC8: Demonstrate creative problem solv ing and flexible th inking to unusual challenges within his/her functiona l responsibilities to respond to a bioterrorism event. The AC8 variable was demonstrated using two questions. If the subject had current knowledge of the medical aspects of the management of bioterrorism related illnesses (question 45, “Very Good” or “Good”), a value of one was assigned to variable AC7Solve and if the subject had been trained for chemical or biol ogical terrorism (question 25, answer of “Yes”), the value of on e was assigned to variable AC8Trained. The variable called AC8 was assigned a sc ore of one, if both AC8Solve and AC8Trained have a score of

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67 one. If either AC8Solve or AC8Train have a value of zero, a ze ro was assigned to AC8. If the subject did not have current knowledge of the medical aspects of the management of bioterrorism related illnesses (question 45, answ er of “Fair” or “Poor ”), or if the subject had not been trained for chemi cal or biological terrorism (q uestion 25, answer of “No”), the value of zero was assigned to AC8. Clinical Competencies Level (CCL) The clinical competency level was measured in two terms: 1) the mean percentage of the sample population who were competen t (number of subjects who are competent in each competency divided by total number of subjects), e.g., on average 80% of subjects were competent in the clinical core competencies, and 2) the mean percentage of the individuals’ competency leve l (number of competencies po ssessed by a subject divided by eight), e.g., on average the subjects are comp etent in 70% of the ov erall clinical core competencies. CCL was calculated by the weighted average of each of the eight clinical core competencies (see Figure 3-1) Eight experts assigned the weight to each competency based on a total weight of 100% divided between the ei ght competencies. If the competencies were equally important the we ight is 12.5%. The mean weight of each competency would be calculated from the all assigned weights from the experts. This mean weight was used in the calcula tion of the CCL of the sample. CCL = (0.113*CC1) + (0.118*CC2) + (0.153*CC3) + (0.11*CC4) + (0.129*CC5) + (0.131*CC6) + (0.106*CC7) + (0.14*CC8) Note: The descriptions of CC1-8 are described below.

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68 Clinical Competency 1 (CC1) CC1: Describe his/her expected clinical role in bioterrorism response for the specific practice setting as a part of the institution or co mmunity response. The CC1 variable was demons trated using two questions. If the subject knew their role as a health care provider in a suspected bioterrorism attack in their community (question 35, “Strongly Agree” or “Agree”), a value of one was assigned to variable CC1Role and if the subject knew their role according to th e organization’s emergency response / disaster plan (ques tion 16, answer of “Yes”), the value of one was assigned to variable CC1Role2. The variable called CC1 was be a ssigned a score of one, if both CC1Role and CC1Role2 had a score of one If either CC1Role or CC1Role2 had a value of zero, a zero was assigned to CC1. If the subject did not know th eir role as a health care provider in a suspected bioterrorism attack in their community (question 35, answer of “Neither Agree or Disagree”, “Disagree” or “Strongly Disagree”), or if the subject did not know their role according to the organiza tion’s emergency response / disaster plan (question 16, answer of “No”), the value of zero was as signed to CC1. Clinical Competency 2 (CC2) CC2: Respond to an emergency within th e emergency management system of his/her practice, institution and community. The CC2 was demonstrated in one question (question 50). If the subject was willing to respond to a high risk event bioterro rism event that aff ected their community (“Very Likely” or “Somewhat Likely”), the valu e of one was assigned to this variable. If the subject was not willing to re spond to a high risk event biot errorism event that affected

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69 their community (“Neither Likely nor Un likely”, “Somewhat Unlikely” or “Very Unlikely”), the value of zero was assigned. Clinical Competency 3 (CC3) CC3: Recognize an illness or in jury as potentially resu lting from exposure to a biological, chemical or radiological agent possibly associated with a terrorist event. The CC3 was demonstrated in questions 46, 47, 48, and 49. These questions tested the current knowledge of the subject to recognize an illn ess or injury as potentially resulting from exposure to a biol ogical agent used in a terrori sm attack. If the subject could answer at least 50 percent of the questi ons correctly, the value of one was assigned. If the subject could no t answer 50 percent of the questions correc tly, the value of zero was assigned. Clinical Competency 4 (CC4) CC4: Ability to report iden tified cases or event s to the public health authorities to facilitate surveillance and investigation using the established institutional or local communication protocol The CC4 was demonstrated in one question (question 38) If the subject knew whom to call to report / re fer a suspected bioterrorism attack (“Strongly Agree” or “Agree”), the value of one was assigned to th is variable. If the subject did not know whom to call to report / re fer a suspected bioterrorism attack (“Neither Agree nor Disagree”, “Disagree” or “Strongly Disagr ee”), the value of zero was assigned.

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70 Clinical Competency 5 (CC5) CC5: Initiate patient care with in his/her professional scope of practice and arrange for prompt referral appropriate to the identified condition(s). The CC5 variable was demons trated using two questions. If the subject had current knowledge of the medical aspects of the di agnosis of bioterrorism related illnesses (question 44, “Very Good” or “Good”), a value of one was assigned to variable CC5Diagn and if the subject had curren t knowledge of the medical asp ects of the management of bioterrorism related illnesses (question 45, “Very Good” or “Good”), the value of one was assigned to variable CC5Manage. The variable called CC5 was assigned a score of one, if both CC5Diagn and CC5Manage had a score of on e. If either CC5Diagn or CC5Manage had a value of zero, a zero was assigned to CC5. If the subject did not have current knowledge of the medical aspects of the di agnosis of bioterrorism related illnesses (question 44, answer of “Fair” or “Poor”), or if the subject did not have current knowledge of the medical aspects of the management of bioterrorism related illnesses (question 45, answer of “Fair” or “Poor”), the value of zero wa s assigned to CC5. Clinical Competency 6 (CC6) CC6: Communicate risks and actions taken to patients and concerned others clearly and accurately. The CC6 was demonstrated in one question (question 45). If the subject had current knowledge of the medi cal aspects of the management of bioterrorism related illnesses, which included communicating risks to the patient (“Very Good” or “Good”), the value of one was assigned to this variable. If the subject did not have current knowledge of the medical aspects of the management of bi oterrorism related illnesses,

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71 which included communicating ri sks to the patient (“Fair” or “Poor”), the value of zero was assigned. Clinical Competency 7 (CC7) CC7: Recognize and manage the psychologica l impact of a Bioterrorism event on victims and health care professional s, as appropriate to the event. The CC7 was demonstrated in one question (question 40) If the subject could recognize and treat the psychol ogical effects to vi ctims and health car e professionals due to bioterrorism attack (“Strongly Agree” or “Agree”), the value of one was assigned to this variable. If the subject could not recognize and treat the psychological effects to victims and health care profes sionals due to bioterrorism attack (“Neither Agree nor Disagree”, “Disagree” or “Strongly Disagr ee”), the value of zero was assigned. Clinical Competency 8 (CC8) CC8: Recognize unusual events that might indicate an emergency and describe appropriate action. The CC8 was demonstrated in one question (question 39) If the subject could recognize signs and symptoms of an illness du e to bioterrorism in their own patients (“Strongly Agree” or “Agree”), th e value of one was assigned to this variable. If the subject could not recognize signs and symptoms of an illness due to bioterrorism in their own patients (“Neither Agree nor Disagree”, “Disagree” or “Str ongly Disagree”), the value of zero was assigned.

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72 Bioterrorism Competency Level (BCL) Bioterrorism competency level was the ov erall weighted mean scores of the ACL and the CCL. Eight experts assigned the we ight to the BCL based on a total weight of 100% divided between ACL and CCL. There were two types of measurements of the BCL corresponding to the measurements of th e ACL and the CCL, of which : 1) the mean percentage of the samp le population who were competen t (number of subjects who were competent in each competency divi ded by total number of subjects), e.g., on average 80% of subjects were competent in all core competencies, and 2) the mean percentage of the individuals’ competency le vel (number of competencies possessed by a subject divided by eight), e.g., on average the subjects were co mpetent in 70% of all core competencies. BCL = (0.364*ACL) + (0.636*CCL) BCL: Bioterrorism competency level ACL: Administrative competency level CCL: Clinical competency level Preparedness Level (PL) Preparedness level is comprised of two components: h ealthcare provider willingness to response at the statewide level (HCPWLstatewide) and the bioterrorism competency level (BCL). The researcher created the PL vari able based on matching each subject in HCPWLstatewide and BCL. To have the PL value coded as “prepared” (value of 1), the subject had a HCPWLstatewide “willing to respond” value greater than 50% of the time, and had a BCL “competency level” that is greater than 50%. If the subjects did not follow the above inclusion criteria, the PL va lue was coded as “not prepared” (value of

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73 0). Matching was used because the subject may have had a high bioterrorism competency level (BCL = 100%) but not willing to respond to an event in Florida (HCPWLstatewide = 0%), or vice-versa ( BCL = 0% and HCPWLstatewide = 100%). To be prepared, the subject must have been willing to respond to a biot errorism event and must have had a minimal level of competency to effectively function without endangering hi m/herself and others. If HCPWLstatewide > 50% AND BCL > 50%, PL = 1 Or, If HCPWLstatewide < = 50% OR BCL < = 50%, PL = 0 The PLoverall was calculated by the number of subjects who are prepared (PL=1) divided by total number of sample subjects. PLoverall = Number of s ubjects with PL=1 Total number of sample subjects Perceived Benefits of Biot errorism Training (PBT) This variable was measured by a ques tion (question 43) asking whether they perceived it was important to have bioterro rism preparedness trai ning. The scale was 3point scale: not important at all (a score of 0) important (1), and very important (2). The PBT variable was tested in the logistic regression model as to whether it predicted the PL or did not predict the PL. Perceived Threats of the Risk of a Biot errorism Attack in the Local Community (PTR) This variable was measured by a ques tion (question 33) asking whether they perceived threats of the risk of a bioterrorism attack within the provider’s local

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74 community. The scale is 5-point Likert scale: strongly disagree to strongly agree (1-5, respectively). The PTR variable was tested in the logis tic regression model as to whether it predicted the PL or did not predict the PL. Healthcare Providers’ “Feeling” Prepared (FP) The healthcare providers’ “feeling” prepared was measured by one question (question 58) asking whether they felt prepared to diagnose and manage the bioterrorism attack. The scale is 3-point s cale: not prepared (a score of 0), somewhat prepared (1), and very prepared (2). Previous Participation in Preparedness Drills (PPD) Previous participation in preparedness drills was assessed by one question (question 21). If the subjects participated in any preparedness drills the value of one was assigned to this variable. If th e subjects did not participate in the disaster dril ls within the last 12 months, the value of zero was assigned. The PPD variable was tested in the logistic regression model as to whether it predicted the PL or did not predict the PL. Previous participation in Preparedness Trainings (PPT) The previous participation in prepared ness trainings was asked assessed one question (question 23). If th e subject participated in any preparedness trai nings, the value of one was assigned to this va riable. If the subject did not pa rticipate in the preparedness trainings, the value of zero was assigned. The PPT variable was tested in the logistic regression model as to whether it predic ted the PL or did not predict the PL.

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75 DATA ANALYSES 1. Are Florida’s community healthcare providers (physicians, pharmacists and nurses) prepared to identify and manage a bioterrorism attack? The percentage of overall preparedness level (PLoverall) of all subjects in the study is presented in Chapter 4. 2. Are the levels of pre paredness to respond to a bioterrorism attack different among physicians, pharmacists, and nurses? The percentages of overall preparedness level (PLoverall) of each professional grouping (physicians, pharmacists, and nu rses) was compared using Chi-Square test ( 2 ) at a significanc e level of .05. ( = .05). 3. Do Florida’ healthcare providers (phy sicians, pharmacists and nurses) “Feel” prepared to identify and m anage a bioterrorism attack? The percentages of the Florida’s healthcar e providers who did not “Feel” prepared (“not prepared” vs. “somewhat prepared” and “very prepared”) is presented in Chapter 4.

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76 4. Do previous emergency preparedness traini ngs and drills predic t the overall level of preparedness of the healthcare providers? Logistic regression analysis was used to test whether the prev ious training or drills predicted the prep aredness level (PL) at si gnificance level of .05 ( = .05). PL = 0 + 1x1 + 2x2 + (Model 1) 0: intercept of the model x1 : Previous participation in preparedness drills (PPD) x2 : Previous participation in preparedness training (PPT) Note: x1 and 2 are categorical variables 5. Do previous emergency preparedness trai nings and drills pred ict the Florida’s healthcare providers’ wi llingness to respond to a biological terrorism attack within the Stat e of Florida? Logistic regression analysis was used to test whether the prev ious training or drills predicted the health care provider’s willingness to respond within the State of Florida (HCPWLstatewide) at significance level of .05 ( = .05). HCPWLstatewide = 0 + 1x1+ 2x2 + (Model 2) 0: intercept of the model 1-2 : coefficient of each factor : error term x1 : Previous participation in preparedness drills (PPD) x2 : Previous participation in preparedness training (PPT) Note: x1-2 are categori cal variables

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77 6. Are Florida’s community healthcare providers (p hysicians, pharmacists and nurses) willing to respond to biologic al agent attacks within their local community ? The percentage of Florida’s healthcare providers (HCPWLlocal) is presented in Chapter 4. 7. Are Florida’s community healthcare providers (p hysicians, pharmacists and nurses) willing to respond to biologic al agent attacks outside their local community (Statewide) ? The percentage of Florida’s healthcare providers (HCPWLStatewide) is presented in Chapter 4. 8. Do demographic factors of Florida’ s community healthcare providers (physicians, pharmacists and nurses) predic t a biological terrorism overall level of preparedness? Logistic regression analysis was used to test whether the demographic factors predicted the preparedness level (P L) at significance level of .05 ( = .05). PL = 0 + 1x1+ 2x2 + 3x3 + 4x4 + 5x5 + 6x6 + 7x7 + 8x8 + 9x9 + 10x10 + 11x11 + 12x12 + 13x13 + (Model 3) 0: intercept of the model 1-13 : coefficient of each factor

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78 x1 : age x2 : gender x3 : race x4 : highest educational degree x5 : years worked as licensed professional x6 : current position x7 : employment status x8 : feeling of being prepared x9 : zip code x10 : patient encounter volume x11 : city type x12 : population size x13 : workplace type Note: x1-13 are categori cal variables 9. Does the perceived benefit of bioterro rism preparedness training predict the overall level of preparedness of the healthcare providers? Logistic regression analysis was used to test whether the perceived benefits of bioterrorism preparedness training (PBT) predict the preparedness level (PL) at significance level of .05 ( = .05). PL = 0 + 1x1 + (Model 4) 0: intercept of the model 1: coefficient of perceived benefits factor x1 : Perceived benefits of bioterrorism training (PBT) Note: x1 is ordinal variables

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79 10. Does the perceived threat that a provid er's community is at real risk of a bioterrorism attack predict the overall level of preparedness of the healthcare providers? Logistic regression analysis was used to test whether th e perceived threats of risks of a bioterrorism attack (PTR) predicted the overall preparedness level (PL) at significance level of .05 ( = .05). PL = 0 + 1x1 + (Model 5) 0: intercept of the model 1 : coefficient of percei ved threats factor x1 : Perceived threats of bioterrorism attack in a local community (PTR) Note: x1 is ordinal variables 11. Do the demographics, perceived threat of bioterrorism attack, perceived benefits of bioterrorism training, previous traini ngs, and previous drills predict the level of preparedness of the healthcare providers? Logistic regression analysis was used to test whether the de mographic factors, perceived threats and benefits, and prev ious training and drills predicted the preparedness level (PL) at significance level of .05 ( = .05). PL= 0 + 1x1+ 2x2 + 3x3 + 4x4 + 5x5 + 6x6 + 7x7 + 8x8 + 9x9 + 10x10 + 11x11 + 12x12 + 13x13 + 14x14 + 15x15 + 16x16 + 17x17 + (Model 6) 0: intercept of the model 1-17 : coefficient of each factor x1 : age x2 : gender x3 : race

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80 x4 : highest educational degree x5 : years worked as licensed professional x6 : current position x7 : employment status x8 : feeling of being prepared x9 : zip code x10 : patient encounter volume x11 : city type x12 : population size x13 : workplace type x14 : Previous participation in preparedness drills (PPD) x15 : Previous participation in preparedness training (PPT) x16 : Perceived benefits of bioterrorism training (PBT) x17 : Perceived threats of bioterrorism attack in a local community (PTR) Note: x1-15 are categorical variables, x16 and x17 are ordinal variab les (3-point and 5-point Likert scale, respec tively); the bold text represents the studied factors addressed in this question.

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81 “… with terrorist groups today… we’re in a new era… where the unthinkable could be done with unthin kable destructive power by groups that are willing to do the unthinkable.” Senator Sam Nunn, 1996

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82 CHAPTER 4 RESULTS This chapter first discusses the dist ribution of the ques tionnaire, and the descriptions of the study subj ects and their work place. Se cond, it details the assessment of the healthcare providers’ competency leve ls and willingness to respond to determine the overall preparedness level of Florida h ealthcare providers. Fi nally, it presents the findings of the predictive mode ling of an individual’s ov erall preparedness level. Distribution of the Questionnaire Of 22,800 questionnaire invitations sent to Florida healthcare pr oviders by e-mail, 9,124 were assumed delivered, 13,676 mails were returned for reasons of an “unknown address”, “incorrect address” or were “blocked” by a sp am filter. There were 2,879 healthcare providers from the 9,124 who receive d the e-mails that came to the study website and 2,279 opted into the study, whic h represent the study response rate of 24.97% (2,279/9,124). The survey was opened for 7 days, from midnight Sunday until midnight of the following Saturday. There was only one reminder sent out to all providers on Tuesday of that week. From the 2,279 surveys that were started, 1,957 were completed (85.9%). Since the survey required the subjects to complete each questi on in sequence from

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83 question 1 to 59, all question data were capt ured up to the point the subjects completed (n=1,957) or prematurely exited the su rvey (incomplete su rvey, n=349). Description of the Study Subjects The composition of th e survey participants were majority nurses (n=1,152, 50.5%, see Table 4-1), but also included ph armacists (n=486, 21.3%), physicians (n=604, 26.5%), and “others”, which the provider type co uld not be defined (i .e. professor, n=37, 1.6%). The greater part of the subjects were female (n =1,275, 58.3%) and most of the providers were within the 35 to 54 year age range (n=1,329, 60.5%). Only 55 (2.5%) African Americans and 139 (6.4 %) Hispanics participated. Table 4-1 Florida Healthcare Providers’ Demographics All Healthcare Providers (%) Physician (%) Nurse (%) Pharmacist (%) Others (%) Age (n=2,198) 18-34 35-54 >55 371 (16.9) 1,329 (60.5) 498 (22.6) 63 (10.4) 345 (50.7) 196 (32.5) 163 (15.2) 687 (64.0) 223 (20.8) 142 (29.2) 276 (56.8) 68 (14.0) 3 (8.3) 22 (61.1) 11 (30.6) Gender (n=2,188) Male Female 913 (41.7) 1275 (58.3) 483 (80.1) 120 (19.9 158 (14.9) 905 (85.1) 263 (54.1) 223 (45.9) 9 (25) 27(75) Race (n=2,182) African American American Indian Asian / Pacific Island Caucasian Hispanic Other 55 (2.5) 8 (.4) 108 (4.7) 1801 (82.5) 139 (6.4) 71 (3.3) 11 (1.8) 4 (.7) 39 (6.5) 462 (76.6) 60 (10) 27 (4.5) 21 (2) 3 (.3) 31 (2.9) 944 (89.3) 37 (3.5) 21 (2) 22 (4.5) 1 (.2) 38 (7.8) 361 (74.3) 41 (8.4) 23 (4.7) 1 (2.8) 0 (0) 0 (0) 34 (94.4) 1 (2.8) 0 (0) Highest Degree (n=2,184) Associate Bachelor Masters Doctorate Foreign Educated 288 (13.2) 544 (24.9) 463 (21.2) 852 (39) 37 (1.7) 0 (0) 0 (0) 0 (0) 594 (98.5) 9 (1.5) 281 (26.5) 302 (28.5) 416 (39.3) 38 (3.6) 22 (2.1) 0 (0) 233 (48.1) 34 (7.0) 212 (43.6) 6 (1.2) 5 (13.9) 8 (22.2) 11 (30.6) 12 (33.3) 0 (0) Years of Work Experience (n=2,168) < 2 3 to 5 6 to 10 11 to 20 > 20 76 (3.5) 206 (9.5) 323 (14.9) 542 (25) 1021(47) 34 (5.6) 52 (8.6) 77 (12.8) 156 (25.9) 284 (47.1) 22 (2.1) 77 (7.4) 146 (14) 254 (24.4) 544 (52.2) 20 (4.1) 75 (15.4) 94 (19.3) 120 (24.7) 176 (36.2) 0 (0) 2 (5.6) 6 (16.7) 12 (33.3) 16 (44.4) N is based on the number of completion of each question

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84 As expected, every subject had at least a two-year college de gree (n=288, 13.2%), with the majority having doctorate de grees (DO, Ph.D., MD, PharmD, DDS, n=852, 39.0%). There were 32 (1.7%) foreign ed ucated subjects. While receiving good representation in all groupings, significant proportion of the most subjects had over 20 years of work experience as a license d provider (physicians n=284, 47.1%, nurses, n=544, 52.2%, and pharmacists n=176, 36.2%). Description of the Subjects’ Work Place Most of the subjects work ed in a health care set ting (n=1,863, 86.2%, see Table 42), more precisely a hospital setting (hos pital, none teaching n=470, 25.2% and teaching hospital n=331, 17.8%). The on ly exception was the pharm acist. While this subgroup had a large presence in hospitals (n=123, 28.4%), the primary work place was in a community pharmacy (n=197, 45.8%). There were also a to tal of 230 (12.4%) retirees that participated in the surv ey. While it was unknown whethe r the retirees continued to practice, this segment continued to echo th e subject population at large in this study. There were not significant diffe rences in the data examined. The majority of the subject s worked in an urban ar ea (n=1,084, 50.9%), with a population base greater than 75,000 (large c ity, n=1,296, 61%). The patient encounters of the subject’s workplace were normally le ss than 5,000 annually ( 558, 30.2%), with the exception of the pharmacist segmentation. Its largest subgroup (n=76, 17.8%) received greater than 80,000 en counters yearly.

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85Table 4-2 Florida Healthcare Provi ders’ Work Place Demographics All Healthcare Providers (%) Physician (%) Nurse (%) Pharmacist (%) Others (%) Work Place Setting (n=2,162) Health Care None Health Care Unemployed 1863 (86.2) 179 (8.3) 120 (5.6) 530 (88) 29 (4.8) 43 (7.1) 895 (86.1) 91 (8.1) 54 (5.2) 431 (89) 38 (7.9) 15 (3.1) 7 (19.4) 21 (58.3) 8 (22.3) Primarily Work Place (n=1,862) Hospital, none Teaching Teaching Hospital Long-term Care Facility Home Health Care Private Single Practice Private MultiPhysician Practice Clinic Setting Institutional Pharmacy Community Pharmacy University/Research Retired 470 (25.2) 331 (17.8) 47 (2.5) 37 (2) 145 (7.8) 179 (9.6) 158 (8.5) 21 (1.1) 197 (10.6) 47 (2.5) 230 (12.4) 96 (18.1) 108 (20.4) 1 (.2) 1 (.2) 103 (19.5) 107 (20.2) 53 (10) 0 (0) 0 (0) 14 (2.6) 46 (8.7) 295 (32.9) 177 (19.8) 30 (3.3) 30 (3.3) 42 (4.7) 69 (7.7) 88 (9.8) 1 (.1) 0 (0) 28 (3.1) 136 (15.2) 76 (17.7) 46 (10.7) 16 (3.7) 6 (1.4) 0 (0) 2 (.5) 17 (4) 20 (4.7) 197 (45.8) 2 (.5) 48 (11.2) 3 (42.9) 0 (0) 0 (0) 0 (0) 0 (0) 1 (14.3) 0 (0) 0 (0) 0 (0) 3 (42.9) 0 (0) Yearly Patient Encounters (n=1,848) < 5000 5,000 9,999 10,000 -19,999 20,000 – 39,999 40,000 – 59,999 60,000 – 79,999 > 80,000 Not Applicable 558 (30.2) 291 (15.7) 206 (11.1) 202 (10.9) 147 (8) 83 (4.5) 223 (9.8) 138 (7.5) 200 (38) 99 (18.8) 53 (10.1) 49 (9.3) 19 (3.6) 17 (3.2) 56 (10.6) 34 (6.5) 289 (32.5) 139 (15.7) 97 (10.9) 97 (10.9) 75 (8.4) 43 (4.8) 91 (10.2) 57 (6.4) 68 (16) 51 (12) 56 (13.1) 53 (12.4) 53 (12.4) 22 (5.2) 76 (17.8) 47 (11) 1 (14.3) 2 (28.6) 0 (0) 3 (42.9) 0 (0) 1 (14.3) 0 (0) 0 (0) Community Type (n=2,128) Rural Urban Suburban 244 (11.5) 1084 (50.9) 800 (37.6) 56 (9.5) 310 (52.5) 225 (38.1) 125 (12.2) 522 (50.9) 379 (36.9) 56 (11.8) 229 (48.2) 190 (40) 7 (19.4) 23 (63.9) 6 (16.7) Population Size (n=2124) Small City (< 25,000) Med City (25,000 75,000) Large City (> 75,000) 213 (10) 615 (29) 1296 (61) 44 (7.5) 140 (23.7) 406 (68.8) 103 (10.1) 332 (32.4) 589 (57.5) 63 (13.3) 133 (28.1) 278 (58.6) 3 (8.3) 10 (27.8) 23 (63.9) N is based on the number of completion of each question Assessment of the Provider’s Current Preparedness Levels According to the study’s co nceptual model, the asse ssment of the provider’s current preparedness levels involved 4 steps. First, it needed to determine the subject’s eight core administrative competencies (AC1-8) and the eight core clinical competencies (CC1-8) levels. These findings could be used to determin e which competency area in which an individual might ha ve had a weakness, or an ar ea which an organization may target for training of a group of providers.

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86 Second, the weighted administrative comp etency level (ACL) and the weighted clinical competency level (CCL), which formed the weighted bioterrorism competency level (BCL), were calculated. The BCL, in itself, indicated the provider’s individual overall bioterrorism competency level. Third, the provider’s willingness to respond to a statewide event was determined and assigned a score. This score could be used to estimat e a response rate (number of providers willing to respond di vided by the local population of providers) of volunteer medical providers for pre-ev ent planning activities. Finally, the BCL was matche d with the provider’s w illingness-to-respond rating to form the provider’s overall preparedness leve l (PL) score. This score was used for the overall preparedness level of the providers. The actual measuremen ts for each of these processes (steps 1-4) are outlined in Chapter 3. Determine the Providers’ Compet ency Levels (AC1-8 and CC1-8) Administrative Competencies (AC) Nurses (65.2%) had a higher administrative competency level than the physicians (59.1%) and pharmacists (54.9%) on the un-we ighted administrative competencies. Further examination of the individual core administrative competencies revealed that healthcare providers as a whol e are the most competent at demonstrating the correct use of communication equipment used for emergency communication (see Figure 4-1, AC5, all 72.7%, physicians 76.3%, nurses 74.3%, and pharmacists 66.2%), and being able to describe his/her functional role(s) in emerge ncy response, and parta king in these role(s) during regular drills (AC4, all 70.1%, physicians 72.3 %, nurses 69.3%, and pharmacists

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87 70.1%). The survey findings, shown on Table 4-3, also suggests that the subjects could problem solve creatively and appl y flexible thinking to unusual challenges within his/her functional responsibilities during a response to a bioterrorism event (AC8 all 70.6%, physicians 71.3%, nurses 66.5%, and pharmacists 78.5%). 0 10 20 30 40 50 60 70 80 90 100 Level (%) AC1AC2AC3AC4AC5AC6AC7AC8 Competencies p() All Healthcare Providers Physician Nurse Pharmacist Figure 4-1. Provider Admi nistrative Competency Levels fo r Bioterrorism Preparedness. Overall, physicians and pharm acists were the weakest at identifying limits to own knowledge, skill, and authority, and identify key system resources for referring matters that exceed these limits (AC7, physicians 45.2% and phar macists 24.7%). The nurses’ weakest competency was their lack of knowledge of his/her work place’s role in an emergency response (AC1, 51.9%).

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88 Table 4-3. Administrative Competency Levels of Florida Healthcare Providers All Healthcare Providers (%) Physician (%) Nurse (%) Pharmacist (%) AC1 47.7 46.8 51.9 40.3 AC2 56.1 47.6 64.6 49.3 AC3 57.1 47.6 68.2 46.3 AC4 70.1 72.3 69.3 70.1 AC5 72.7 76.3 74.3 66.2 AC6 67.7 65.3 70.5 64.1 AC7 46.1 45.2 56.6 24.7 AC8 70.6 71.3 66.5 78.5 AC1: Describe your work place’s role in an emergency response. AC2: Identify the chain of command in emergency response. AC3: Identify and locate the agency ’s emergency management plan. AC4: Describe his/her functional role(s ) in emergency response and participate in these role(s) during regular drills. AC5: Demonstrate the correct use of communication equi pment used for emergency communication. (phone, fax, radio, satellite phone) AC6: Ability to locate the communication role(s) in th e emergency response plan and understand his/her role. AC7: Identify limits to own knowledge, skill, and authority, and identify key system resources for referring matters that exceed these limits. AC8: Demonstrates creative problem solving and flexible thinking to unusual challenge s within his/her functional responsibilities to respond to a bioterrorism event. Clinical Competencies (CC) Physicians (48.9%) had a higher compet ency level than th e nurses (44.9%) and pharmacists (37.0%) on the un -weighted clinical competencies. As Figure 4.2 demonstrates, the clinical competency set has more deficits than th e administrative core competency set. The clinical competencies examined skills not afforded by normal job duties such as using a fax, and involve specialized bioterro rism training. The all provider clinical competency le vel for the eight individual un-weighted competencies range from the low of 17.9% (CC5, see Tabl e 4-4), the ability to initiate patient care within his/her pr ofessional scope of practice and arrange for prompt referral appropriate to the id entified condition(s) to the high of 73.9% (C C1), the ability to describe his/her expected clinic al role in bioterrorism res ponse for the specific practice setting as a part of the institution or community response

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89 0 10 20 30 40 50 60 70 80 90 100 Level (%) CC1CC2CC3CC4CC5CC6CC7CC8 Competencies All Healthcare Providers Physician Nurse Pharmacist Figure 4-2. Provider Clinical Competency Levels for Bi oterrorism Preparedness. Within the provider subgroups, physicia ns and pharmacists were the most competent at CC1 and CC2, the ability to respond to an emergency within the emergency management system of his/her practice, institution and community (CC1, 76.5% and 73.3%, and CC2, 76.5% and 71.6%, respectively). Th e nurses were also the most competent at CC1 (72.5%) and showed a strength in CC4 (67.8%), the ability to report identified cases or events to the public health authorities to facilitate su rveillance and investigation using the established ins titutional or local communication protocol. As with the all provider comp etency level, the provider subgroups all demonstrated the lowest competency level in CC5 ( physician 25.7%, nurse 17.4% and pharmacist 9.2%). Physicians demonstrated deficits in their ability to communicate risks and actions taken to patients and concerned others clearly and accurately (CC6, 29.1%) and in their ability to recognize an illness or injury as pote ntially resulting fr om exposure to a biological, chemical or radi ological agent possibly associ ated with a terrorist event (CC3, 34.6%). The nurses also have major deficits in CC3 (18.4%) and CC6 (22.3%).

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90 Additionally, nurses report difficulty in the recognition of unusual events that might indicate an emergency and describe appropriate action (CC8, 37.3%). Th e pharmacist subgroup’s main deficit was CC5 (9.2%). Ot her deficits included CC3 (17.3%), CC6 (15.9%), CC8 (29.5%), and CC7 (24.7%), the ability to reco gnize and manage the psychological impact of a Bioterrorism event on victim s and healthcare professionals. Table 4-4. Clinical Competency Leve ls of Florida Healthcare Providers All Healthcare Providers (%) Physician (%) Nurse (%) Pharmacist (%) CC1 73.9 76.5 72.5 73.3 CC2 70.5 76.5 67.2 71.6 CC3 22.6 34.5 18.4 17.3 CC4 61.4 56.4 67.8 54.6 CC5 17.9 25.7 17.4 9.2 CC6 22.8 29.1 22.3 15.9 CC7 46.1 45.2 56.6 24.7 CC8 38.4 47.3 37.3 29.5 CC1: Describe his/her expected clinical role in bioterrorism response for th e specific practice setting as a part of the institution or community response. CC2: Respond to an emergency within the emergency ma nagement system of his/he r practice, institution and community. CC3: Recognize an illness or injury as potentially re sulting from exposure to a biological, chemical or radiological agent possibly associated with a terrorist event. CC4: Ability to report identified cases or events to the public health authorities to facilitate surveillance and investigation using the established ins titutional or local communication protocol CC5: Initiate patient care within his/her professional scope of practice and arrange for prompt referral appropriate to the identified condition(s). CC6: Communicate risks and actions taken to patients and concerned others clearly and accurately. CC7: Recognize and manage the psychological impact of a Bioterrorism event on victims and health care professionals, as appropriate to the event. CC8: Recognize unusual events that might indicate an emergency and describe appropriate action. Administrative Competency Level (ACL) To calculate the weighted Administrative Competency Level (ACL), the administrative competency resu lts (AC1-8) above were placed in the following formula: ACL = (0.103*AC1) + (0.126*AC2) + (0.103*AC3) + (0.159*AC4) + (0.153*AC5) + (0.062*AC6) + (0.103*AC7) + (0.191*AC8) ACL = 0.6284 Note: The descriptions of ACL and AC1-8 are found in Chapter 3.

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91 This resulted in a mean scor e of 0.6284. This mean score average suggests that 62.84% of subjects are competent in the administrative core competencies, and that on average each subject is competent in 62.84% of the ov erall core administrative competencies. Clinical Competency Level (CCL) To calculate the Clinical Competency Level (CCL), the clinical competency results (CC1-8) above were placed in the following formula: CCL = (0.113*CC1) + (0.118*CC2) + (0.153*CC3) + (0.11*CC4) + (0.129*CC5) + (0.131*CC6) + (0.106*CC7) + (0.14*CC8) CCL = 0.4497 Note: The descriptions of CCL and CC1-8 are f ound in Chapter 3. This resulted in a mean scor e of 0.4497. This mean score average suggests that 44.97% of subjects are competent in the clinical core competenci es, and that on average each subject is competent in 44.97% of the ov erall core administrative competencies. Figure 4-3. Weighted Bi oterrorism Competency Levels Scores for Florida’s Healthcare Providers.

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92 Bioterrorism Competency Level (BCL) To calculate the Bioterrorism Competency Level (BCL), the results from both the ACL and BCL above were placed in the following formula: BCL = (0.364*ACL) + (0.636*CCL) BCL = .5117 Note: The descriptions of BCL are found in Chapter 3. This resulted in a mean scor e of 0.5117. This weighted mean score average suggests that 51.2% of the subjects have the necessary comp etency level to respond to a bioterrorist attack, and that on average each subject is 51.2% competent in the core bioterrorism competencies. Willingness-to-Respond The willingness-to-respond sc ore is segmented into pr oximities and risk levels. Both factors are important for pre-incident planning of personnel expectations. Within this section, results of Research Questions 6 and 7 are presented. Willingness to Respond to an ev ent within their local community Research Question 6 Are Florida’s community hea lthcare providers (physicians, pharmacists and nurses) willing to respond to bi ological agent attacks within their local community ? The study results suggest that most Florida provid ers are willing to respond to both a high risk (HR) event and a low risk (LR) event within their local community (81.7% and 82.8%, respectively). Physic ians are the most likely to respond to a HR event in the

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93 local community (84.5%) and have the tendency to report a higher willingness to respond in a HR event than a LR event, unlike the ot her professions. Nurses are the most likely in a LR event (83.6%) in the local community. Pharmacist are the least likely to respond in all proximity categories (see Table 4-5). Table 4-5. Percentage of Florida Health care Providers Willin g-to-Respond to a Bioterrorism Attack All Healthcare Providers Physician Nurse Pharmacist Proximity n=1961 High Risk Low Risk High Risk Low Risk High Risk Low Risk High Risk Low Risk Local 81.7 82.8 84.5 83.3 81.6 83.6 79.1 80.7 Regional 64.4 68.1 66.5 65.9 65.5 70.4 59.5 64.6 Statewide 53.6 53.8 55.0 51.7 56.9 56.7 45.0 47.0 Nationwide 48.2 47.0 51.9 46.1 47.3 48.9 45.5 44.5 The total n does not include the “others” category of provider. High Risk Event was defined as a bioterrorism agent that doe s NOT have a known treatment and/or vaccination. Low Risk Event was defined as a bioterrorism agent that has a known treatment and/or vaccination. Proximity was defined as the distance from providers’ normal workplace to Ground Zero of the event. Local was defined as the providers’ local community. Regional was defined as counties surrounding the providers’ normal workplace. Statewide was defined as responding anywhere in the State of Florida. Nationwide was defined as responding anywhere in the United States. Willingness to Respond to an ev ent outside their local community Research Question 7. Are Florida’s community hea lthcare providers (physicians, pharmacists and nurses) willing to respond to bi ological agent attacks outside th eir local community (Statewide) ? When asked if Florida’s community health care providers (physicians, pharmacists and nurses) were willing to respond to bi ological agent attacks outside their local community, all subject group percentages dropped dramatically (see Table 4-5). Within the statewide subgroup, only 53.6% of all subj ects reported that they are willing to respond to a HR event (physicians 55.0%, nurses 56.9% and pharmaci sts 45.0%). It was also reported that only 48.2% of Florida’s community provid ers are willing to respond to a HR event and 47.0% to a LR event outside Florida.

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94 Provider Preparedness Level (PL) Figure 4-4. The Scored Conceptual M odel for Bioterrorism Preparedness.

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95 Research Question 1. Are Florida’s community hea lthcare providers (physicians, pharmacists and nurses) prepared to identi fy and manage a biot errorism attack? Overall, 67.5% of the Fl orida healthcare providers were not prepared for a bioterrorism attack. As iden tified by the BCL (see Figure 4-3), 51.1% of subjects have the minimal competencies need ed to respond to a biological attack and 53.7% are willing to respond within the State of Florida (see Table 4-5). When the process of matching was applied to the subjec ts, only 32.5% (34.6% physicians, 38.4% nurses, and 17.4% pharmacist, see Table 4-4) of Florida’s community health care providers had both a minimal level of competency to effectively function without endangering him/herself and others, and are willing to res pond to a bioterrorism attack. Table 4-6. Preparedness Levels of Florida Healthcare Providers Overall Preparedness Provider Type Not Prepared (%) Prepared (%) Physician N=537 351(65.4%) 186 (34.6%) Nurse N=916 564 (61.6%) 352 (38.4%) Pharmacist N=436 360 (82.6%) 76 (17.4%) FL Healthcare Providers N=1889 1275 (67.5%) 614 (32.5%) The total n does not include the “others” category.

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96 Research Question 2. Are the levels of preparedness to respond to a bioterrorism attack different among physicians, pharmacists, and nurses? Pharmacists seemed to be less prepared than physicians a nd nurses (17.4% vs. 34.6%, 38.4%, see Figure 4-5). A Pearson Chi-Squa re test of the percent preparedness of all three groups was performed. It showed that there was at least a significant difference between the levels of preparedness of a pair comparison (Pearson Chi-Square =60.916, df= 2, p=.000). The researcher conducted a family-wise comparisons (alpha = .017) of the preparedness levels between provider types to identify the different. There were statistically significant differ ences of the levels of preparedness between physician and pharmacist groups (34.6% vs. 17.4%, Pears on Chi-Square=36.203, df=1, p=.000) and between nurse and pharmacist groups (38.4% vs. 17.4%, Pearson Chi-Squre = 60.193, df=1, p=.000). There was no significant difference between physicians and nurses (34.6% vs. 38.4%, Pearson Chi-Square = 2.087, df=1, p=.159). 0 20 40 60 80 100 Level (%) Provider Type Prepared 34.638.417.4 Not Pre p ared 65.461.682.6 PhysicansNursesPharmacists Figure 4-5. Overall Bioterrorism Prepar edness Level (PL) by Provider Type.

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97 Research Question 3. Do Florida’ healthcare provid ers (physicians, pharmacists and nurses) “Feel” prepared to identif y and manage a biote rrorism attack? The findings suggest that 55.5% (n=1957) of Florid a’s community healthcare providers do NOT feel prepared (physi cians n=545, 41.7%, nurses n= 943, 55.4%, and pharmacists n=439, 72.4%) and 41.5% feel so mewhat prepared (physicians 51.6%, nurses 42.5%, and pharmacists 27.1 %) to identify and manage a bioterrorism attack (see Figure 4-6). Only 3.0 of Florid a’s providers feel very prep ared (physicians 6.8%, nurses 2.1%, and pharmacists 0.5%). 0 10 20 30 40 50 60 70 80 90 100 Provider Types% Physicans 6.851.641.7 Nurses 2.142.555.4 Pharmacists 0.527.172.4 FL Providers 341.555.5 Very PreparedSomewhat PreparedNot Prepared Figure 4-6. Percentage of Provi ders that “Feel” Prepared.

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98 The Work Place Emergency Plan The findings suggest that 70% (physicia ns 68.9%, nurses 83.1%, and pharmacists 60.5%, see Figure 4-7) of Florida’s community healthcare providers know if their work place has an emergency plan. Of those, only 52.9% (physicians 46.2%, nurses 60.3%, and pharmacists 44.9%) know where it is located. 0 10 20 30 40 50 60 70 80 90 100 % Provider Type Workplace has a plan Knows location Reviewed plan in last 12 months Know role according to plan Has special organization structure (i.e. ICS) Plan specifically addresses bioterrorism Plan specifically addresses emergency communications Workplace has a plan 73.768.983.160.5 Knows location 52.946.260.344.9 Reviewed plan in last 12 months 41.331.649.734.4 Know role according to plan 49.645.456.140.7 Has special organization structure (i.e. ICS) 55.95362.246.3 Plan specifically addresses bioterrorism 39.541.94329 Plan specifically addresses emergency communications 54.65061.245.7 All ProvidersPhysiciansNursesPharmacists Figure 4-7. Provider’s Knowledge of a Work Place Emergency Plan and It’s Contents

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99 Emergency Preparedness Drills The findings suggest that 31.5% (physicians 25.4%, nurse s 40.5%, and pharmacists 20.1%, see Figure 4-8) of Florida’s community healthcare providers had participated in an emergency drill in the la st 12 months. Of those, onl y 11.1% (physicians 10.3%, nurses 13.5%, and pharmacists 6.6%) have participated in a bioterrorism themed drill. 0 5 10 15 20 25 30 35 40 45 50 % Provider Type All Providers Physicians Nurses Pharmacists All Providers 31.511.111.410.23.719 Physicians 25.410.38.89.85.117.2 Nurses 40.513.514.8123.723.8 Pharmacists 20.16.67.26.61.99.7 Participated in any drill Biological agent drill Bomb threat Chemical agent drill Nuclear/radiolo gy agent drill Mass casualty drill Figure 4-8. Provider’s Partic ipation in an Emergenc y Preparedness Drills

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100 Emergency Preparedness Training Activities The findings suggest that 55.2% (physicians 33.2%, nurse s 66.7%, and pharmacists 33.2%, see Figure 4-9) of Florida’s community healthcare pr oviders have participated in an emergency training sometime during thei r career. Of those, only 11.1% (physicians 26.5%, nurses 36.9%, and pharmacists 22%) have participated in tr aining within the previous 12 months and 32.3% st ated that the trai ning included a che mical or biological components. 32.4% of the provide rs stated that the traini ng focused specifically to a biological agent exposure. 010203040506070 % Received Training Within the previous 12 months Was annual “Refresher” Included chemical/biological training for terrorism Biological agent exposure training Bomb threat training Chemical agent exposure training Nuclear/radiology agent training Mass casualty drill training T y p e o f T r a i n i n g Pharmacists Nurses Physicians All Providers Pharmacists 33.22214.420.616.716.917.7821.4 Nurses 66.736.930.940.136.537.237.621.143.5 Physicians 52.926.518.438.737.625.736.127.236.3 All Providers 55.230.823.835.332.429.632.619.836.7 Received Training Within the previous 12 months Was annual “Refresher” Included chemical/biologica l training for Biological agent exposure training Bomb threat training Chemical agent exposure training Nuclear/radiology agent training Mass casualty drill training Figure 4-9. Provider’s Emergency Preparedness Training Activities

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101 Method / Modality of Bioterro rism Training Received The providers reported that 54% received their trai ning in a traditional lecture format and that 21% used self learn materials (s ee Figure 4-10). The providers also suggested that traditional lect ure format (44%) is the preferred choice to obtain future bioterrorism trainings, with online interactive courses (30 %) being the next preferred. Traditional lecture format 54% Online interactive 16% Web-casts, teleconference, or satellite broadcast 9% Self learn, self pace 21% Traditional lecture format 44% Online interactive 30% Web-casts, teleconference, or satellite broadcast 9% Self learn, self pace 17% Figure 4-10. Types of Biote rrorism Training Methods/ Mo dalities for Providers Previous Trainings Preferred Trainings

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102 Perceived Benefits of Biot errorism Training (PBT) When ask how important is it for you to be trained to identify a possible bioterrorism attack 46% of the providers re ported that it was very important, 50% stated it was important and 4% believed it was not important (see Figure 4-11). Very Important 46% Important 50% Not Important 4% Figure 4-11. The Prov iders’ Perceived Benefits of Bioterrorism Training (PBT)

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103 Perceived Threats of the Risk of a Bioterrorism Attack When ask if a bioterrorism attack is a re al threat within Florida 86.4% of the providers either str ongly agreed or agreed. When ask if a bioterrorism attack is a real threat within your local community this percentage dropped to 59.8% that either strongly agreed or agreed, with 40.2% either be ing neutral or disagr eeing. (Figure 4-12). 0 5 10 15 20 25 30 35 40 45 50 % Provider Attitudes Local Florida Local 20.139.727.410.62.2 Florida 3947.410.72.20.7 Strongly AgreeAgree Neither Agree or Disagree DisagreeStrongly Disagree Figure 4-11. The Prov iders Perceived Threats of the Risk of a Bioterrorism Attack at the State and Local Levels

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104 Predictive Factors of Provider Preparedness Levels Research Question 4. Do previous emergency prepared ness trainings and drills predict the overall level of preparedness of the healthcare providers? The dependent variable is PL. If healthcare providers were prepared PL=1,otherwise PL=0(not prepared). Since the dependent variable is discrete, the ordinary least squares regression can be used to fit a linear probability model. However, since the linear probability model is he teroskedastic and may predict probability values beyond the (0,1) range, the logistic regr ession model is used to estima te the factors which influence the overall preparedness. Table 4-7 Descriptive Statistics of the Vari ables in the Logistic Regression Model for Question 4. Variable Frequency (%) Overall preparedness N=1,919 Not prepared (0) Prepared (1) 1,298 (67.6) 621 (32.4) Previous Drills N=2,071 Yes (1) No (2) 653 (31.5) 1,418(68.5) Previous Trainings N=2,068 Yes (1) No (2) 1,141(55.2) 927 (44.8) Table 4-8 Logistic Regression Si gnificant Results for Question 4 B S.E.Wald Df Sig. Exp(B) Disaster Drills (yes) .941.11468.0961 .000 2.562 Participated in Disaster Training (yes)1.049.11779.9151 .000 2.856 Constant -1.696.093335.5351 .000 .183 Table 4-9 Model Summary for Question 4 Step -2 Log Likelihood Cox & Snell R Square Nagelkerke R Square 1 217.838 .120 .167

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105 Table 4-10 Model Prediction for Question 4 Predicted Overall Preparedness Observed Not Prepared Prepared Percentage Correct Step 1 Overall Preparedness Not Prepared 1097 201 84.5 Prepared 336 285 45.9 Overall % 72.0 Note: The Cut Value is 0.500 The results from logistic regression indicate that pr evious trainings (beta = .1049, p=.000) and drills (beta = .941, p=.000) were significant predicto rs of the overall preparedness level of Florida healthcare provi ders at 0.05 level.(Tab le 4-8) By using logistic regression analysis, beta is the regression coef ficient of logarithm of the likelihood of preparedness Log odds of being prepared= log probability of being prepared 1probability of being unprepared In order to interpret the results, exponent ial function of beta of each independent variable is used as a regression coefficien t to predict preparedness (prepared vs. not prepared). If a healthcare provider has prev ious drills, they are 2.56 times likely to be prepared for a bioterrorism attack compared with no previous dr ills. Similarly, if a healthcare provider has previous drills, they are 2.86 times li kely to be prepared for a bioterrorism attack compared with no previous trainings. The ability of variance of PL explained by this model is low (Nagelkerk e R square = .167, see Table 4-9). However,

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106 the model predicts 74% of the responses correctly, see Table 410). The preparedness of the healthcare providers on a biot errorism attack event is mult ifaceted and complex. It is not expected that only previous trainings and drills would have high R square. The predictive model is substituted below. logPL = -.1696+ 0.941 x1 +0.1049 x2 + (Model 1) Research Question 5 Do previous emergency prepared ness trainings and drills predict the Florida’s hea lthcare providers’ willingness to respond to a biological terrorism attack within the State of Florida? The results from logistic regression indicate that pr evious trainings (beta = .286, p=.010) and drills (beta = .436, p=.000) were sign ificant predictors of the willingness to respond of Florida healthcare providers (see Table 4-11). The re searcher used the exponential function of betas to interpret th e prediction of the overall preparedness with similar reasons listed in questi on 4. If the heal thcare providers had pr evious drills, they were 1.55 times more likely to be willingn ess to respond to a bioterrorism attack compared with no previous dril ls. If the healthcar e providers had previo us trainings, they were 1.33 times more likely to be willingn ess to respond to a bioterrorism attack compared with no previous trai nings. The ability of variance explained by this model is low (Nagelkerke R square = .027, see Table 412). However, the model predicts 55.8% of the responses correctly (see Table 4-13). The willingness to respond to a bioterrorism attack of the healthcare providers is multifacet ed and complex. It is not expected that only previous trainings and drills would hi ghly predict the willingn ess to respond. There is no constant included in the model (p=.105) The predictive model is substituted with the regression coefficients below.

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107 Log HCPWLstatewide = 0 + 0.436x1+ 0.286x2 + (Model 2) Table 4-11 Descriptive Statisti cs of the Variables in the Logistic Regression Model for Question 5. Variable Frequency (%) Willingness to Response (Statewide) level N=1,556 No (0) Yes (1) 713(45.8) 843 (54.2) Previous Drills N=2,071 Yes (1) No (2) 653 (31.5) 1,418(68.5) Previous Trainings N=2,068 Yes (1) No (2) 1,141(55.2) 927 (44.8) Table 4-12 Logistic Re gression Significant Results for Question 5 B S.E.Wald Df Sig. Exp(B) Disaster Drills (yes) .431.12013.2081 .000 1.547 Participated in Disaster Training (yes).286.1116.6471 .010 1.331 Constant -.125.0772.6301 .105 .883 Table 4-13 Model Summary for Question 5 Step -2 Log Likelihood Cox & Snell R Square Nagelkerke R Square 1 211.453 .020 .027 Table 4-14 Model Prediction for Question 5 Predicted WTR Statewide Observed Not Willing Willing Percentage Correct Step 1 WTR Statewide Not Willing 321 392 45.0 Willing 298 548 65.0 Overall % 55.8 Note: The Cut Value is 0.500 and WTR = Willingness to Respond

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108 Research Question 8. Do demographic factors of Fl orida’s community healthcare providers (physicians, pharmacists and nurses) predict a biological terrorism overall level of preparedness? The researcher selected the model of the regression anal ysis in step 5, which was the final step of the regression analysis using the b ackward elimination method. The results from logistic regression show that gender (male, beta=.280, p=. 042), city type (rural, beta=.416, p=.020), current posi tion (physician, beta=-1.992, p=.033), and primary work place (home health care, priv ate single practice setting, or private multi-physician practice beta= -1.396,-.705,-.908, p=.007, .005, .000, respectively) were significant predictors of overall preparedness of the Flor ida’s healthcare providers (see Table 4-15). If the healthcare providers were male, they were 1.32 times more likely to be prepared for the bioterrorism attack than female. If the healthcare providers worked in a rural area, they were 1.52 times more likely to be prep ared for the bioterrori sm attack than in a suburban area. If the h ealthcare providers were physicians or pharmacists, they were less likely to be prepared for the bioterrorism attack than providers in academia (i.e. professors). If the healthcar e provider’s primary work pl ace was home health care, a private single practice setting, or a private multi-physician pr actice, they were less likely to be prepared for the bioterro rism attack than a retiree. The ability of variance explained by this model is moderate (Nagelkerke R sq uare = .107, see Table 4-16). However, the model predicts 67.7% of the re sponses correctly (see Table 4-17). There mi ght be other variables that were not meas ured in this study that pr edict the preparedness for a bioterrorism attack of the Florida health care providers. The predictive model is substituted below.

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109 Log PL = .280x2_male -1.992x6_1 -2.577x6_3 -.037x8_4 -.705x8_5 -.908x8_6 + .416x11_1 + (Model 3) Table 4-15 Logistic Re gression of Significant Results for Question 8 Variable B S.E. Wald DfSig. Exp (B) Gender (male) .280 .1374.148 1 .042 1.323 City type rural .416 .178 6.480 5.449 2 1 .039 .020 1.516 Current position physician pharmacist -1.992 -2.577 .934 .935 33.408 4.548 7.604 3 1 1 .000 .033 .006 .136 .076 Work duties home health care private practice private multi-physician practice -1.396 -.705 -.908 .516 .251 .242 37.622 7.334 7.912 14.121 10 1 1 1 .000 .007 .005 .000 .248 .494 .403 Table 4-16 Model Summary for Question 8 Step -2 Log Likelihood Cox & Snell R Square Nagelkerke R Square 1 198.629 .084 .117 2 198.673 .084 .117 3 198.938 .083 .115 4 199.299 .081 .112 5 200.012 .077 .107

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110 Table 4-17 Model Prediction for Question 8 Predicted Overall Preparedness Observed Not Prepared Prepared Percentage Correct Step 1 Overall Preparedness Not Prepared 1097 201 84.5 Prepared 336 285 45.9 Overall % 72.0 Step 2 Overall Preparedness Not Prepared 1060 54 95.2 Prepared 480 80 14.3 Overall % 68.1 Step 3 Overall Preparedness Not Prepared 1055 59 94.7 Prepared 479 81 14.5 Overall % 67.9 Step 4 Overall Preparedness Not Prepared 1058 56 95.0 Prepared 483 77 13.8 Overall % 67.8 Step 5 Overall Preparedness Not Prepared 1061 53 95.2 Prepared 488 72 12.9 Overall % 67.7 Note: The Cut Value is 0.500

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111 Research Question 9 Does the perceived benefit of bi oterrorism preparedness training predict the overall level of preparedness of the healthcare providers? The results from the logistic regression show that percei ved benefits of training was significant predictors of the overall prepared ness level of Florida’s community healthcare providers (beta = -2.158, p=.000 for “no per ceived benefits”, Ta ble 4-18). If the healthcare providers did not pe rceived benefits of bioterro rism training, they are less likely to be prepared for bioterrorism atta ck. The ability of vari ance explained by this model is low (Nagelkerke R square = .024, see Ta ble 4-19). However, the model predicts 67.6% of the responses correc tly (see Table 4-20). Th e preparedness of Florida’s community healthcare providers for a biot errorism attack event is considered multifaceted and complex. It is not expected that only the perception of benefits of bioterrorism training would have high R sq uare. The model is substituted below. PL =-1.786 – 2.158 X1 + (Model 4) Table 4-18 Logistic Re gression Significant Results for Question 9 B S.E. Wald Df Sig. Exp(B) Participated in Disaster Training (yes)-2.158.51617.4581 .000 .116 Constant -1.768.25846.8791 .000 .171 Table 4-19 Model Summary for Question 9 Step -2 Log Likelihood Cox & Snell R Square Nagelkerke R Square 1 238.324 .017 .024

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112 Table 4-20 Model Prediction for Question 9 Predicted Overall Preparedness Observed Not Prepared Prepared Percentage Correct Step 1 Overall Preparedness Not Prepared 1298 0 100 Prepared 621 0 0 Overall % 67.7 Note: The Cut Value is 0.500 Research Question 10 Does the perceived threat that a provider's community is at real risk of a bioterrorism attack predict the o verall level of preparedness of the healthcare providers? The results from the logistic regression show that percei ved threats of bioterrorism attack in the community was significant predic tors of the overall pr eparedness level of Florida healthcare providers (beta = -.224, p=.026 for “no per ceived threats”, see Tables 4-21). If the healthcare provide rs did not perceive threats of bioterrorism attack in the local community, they are less likely to be prepared for the biote rrorism attack. The ability of variance explained by this model is low (Nagelke rke R square = .004, see Table 4-22). However, the model predicts 67.6% of th e responses correctly (s ee Table 4-23). It is not expected that only th e perception of threats of bi oterrorism attack in local communities would have high R square. The predictive model is substituted below. Log PL = -.651 -.224x1 + (Model 5) Table 4-21 Logistic Re gression Significant Results for Question 10 B S.E. Wald DfSig. Exp(B) Perceived Threat (yes) -.224.1014.9431.026.799 Constant -.651.062110.1841.000.522

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113 Table 4-22 Model Summary for Question 10 Step -2 Log Likelihood Cox & Snell R Square Nagelkerke R Square 1 241.126 .003 .004 Table 4-23 Model Prediction for Question 10 Predicted Overall Preparedness Observed Not Prepared Prepared Percentage Correct Step 1 Overall Preparedness Not Prepared 1298 0 100 Prepared 621 0 0 Overall % 67.7 Note: The Cut Value is 0.500 Research Question 11. Do the demographics, perceived th reat of bioterrorism attack, perceived benefits of bioterrorism training, previous trainings, and previous drills predict the level of preparedness of the healthcare providers? The researcher selected the model of the regression anal ysis in step 9, which was the final step of the regression analysis using backward elim ination method. The results from logistic regression show that race ( 1, beta=-.965, p=. 000 and 4, beta=-1.383, p=.002), perceived benefit (beta=2.425, p=.001), previo us drills (beta=.689, p=.000), previous training (beta= .459, p=.002), and feeling not prepared (beta = -3.201, p=.000) were significant predictors of overall preparedness of the Florida healthcare providers (see Table 4-27). If the h ealthcare providers were Caucasian, As ian/ Pacific Islander, or just felt unprepared, they are less likely to be pr epared for the bioterro rism attack. On the other hand, if healthcare provide rs have a perception of thr eats of bioterrorism attack, perceive benefits of bioterrori sm training, had previous drills and trainings, they are more likely to be prepared. The ability of va riance explained by this model is moderate

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114 (Nagelkerke R square = .370, see Table 4-28). However, the model pr edicts 76.9% of the responses correctly, see Table 4-29). The preparedness of the healthcare providers on a bioterrorism attack event is multifaceted and co mplex. There might be other variables that were not measured in th is study predict the preparedness to a bioterrorism attack of the Florida healthcare providers. The predictive model is substituted below. Log PL = -.950x3(1) -1.383x3(4) + 2.425x43 + .689x21_1 +.459x23_1 3.201x58_1 1.459x58_2 + Table 4-24 Logistic Re gression Significant Results for Question 11 B S.E.Wald Df Sig. Exp(B) Race Caucasian Asian / Pacific Islander -.950 -1.383 .334 .438 13.342 8.073 9.980 5 1 1 .02 .004 .002 .387 .251 Perceived benefits 2.425 .76110.146 1 .00111.307 Previous drills .689 .13725.227 1 .0001.991 Previous trainings .459 .1479.728 1 .0021.583 Feeling Prepared Not Prepared Somewhat Prepared -3.201 -1.459 .404 .389 178.467 62.855 14.060 2 1 1 .000 .000 .000 .041 .233 Table 4-25 Model Summary for Question 11 Step -2 Log Likelihood Cox & Snell R Square Nagelkerke R Square 1 158.125 .281 .389 2 158.174 .280 .389 3 158.483 .279 .387 4 158.513 .279 .387 5 158.793 .278 .385 6 159.824 .273 .379 7 160.557 .270 .375 8 161.248 .267 .370 9 161.381 .266 .370

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115 Table 4-26 Model Prediction for Question 11 Predicted Overall Preparedness Observed Not Prepared Prepared Percentage Correct Step 1 Overall Preparedness Not Prepared 954 157 85.9 Prepared 214 346 61.8 Overall % 77.8 Step 2 Overall Preparedness Not Prepared 953 158 85.8 Prepared 215 345 61.6 Overall % 77.7 Step 3 Overall Preparedness Not Prepared 953 158 85.8 Prepared 214 346 61.8 Overall % 77.7 Step 4 Overall Preparedness Not Prepared 951 160 85.6 Prepared 214 346 61.8 Overall % 77.6 Step 5 Overall Preparedness Not Prepared 953 158 85.8 Prepared 215 345 61.6 Overall % 77.7 Step 6 Overall Preparedness Not Prepared 952 159 85.7 Prepared 219 341 60.9 Overall % 77.4 Step 7 Overall Preparedness Not Prepared 948 163 85.3 Prepared 218 342 61.1 Overall % 77.2 Step 8 Overall Preparedness Not Prepared 943 168 84.9 Prepared 210 350 62.5 Overall % 77.4 Step 9 Overall Preparedness Not Prepared 937 174 84.3 Prepared 212 348 62.1 Overall % 76.9 Note: The Cut Value is 0.500

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116 “Genetic Engineering for Biological Agents? There’d be No Protection. These are the Weapons of the Future and the Future is Coming Closer and Closer.” William Cohen, US Secretary of Defense, 1998

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117 CHAPTER 5 DISSCUSION This study was designed to assess Fl orida’s community healthcare providers’ clinical and administrative competencies to manage a bioterrorism attack, assess their willingness to response to a biological terrorism attack within the St ate of Florida, and assess their current level of overall prepar edness to identify and manage a biological terrorism attack. This chapte r provides discussions on the st udy results, methodology, and its’ limitations. Evaluation of the Demographic Factors Most of the study subject we re between the ages of 35 and 54 years old (15%, see Table 4-17). Since the largest licensed provider group in Fl orida are registered nurses, the majority of the study participants were nur ses (50.5%) and Florida’s smallest licensed provider group are the pharmaci sts and their participation wa s also reflective (21.3%). There were more female (58.3%) respondents than males (41.7%). This was probably based on the larger representati on of the nurses within the stu dy. Nurses are still majority female. The greater part of the s ubjects was Caucasian (82.5%), followed by the Hispanics (6.4%). There were only 48 (2.5%) African Americans, 108 (4.7%) Asians / Pacific Islanders, and 7 (0.4%) Amer ican Indians. The researcher was unable to find the

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118 population percentages of minor ities practicing in Florid a to compare whether the minority groupings were accura tely represented. The reasons for a lower participation among African Americans are unknown. Most of the subjects have a Doctorate de gree (39%) and have been working as a licensed professional over 20 years (47%). The majority of the providers are currently working in a healthcare setti ng (82.6%) with 5.6% of the subjects were unemployed at the time of the study. The primary workplace fo r the providers was in a hospital setting and with less than 5000 patient encounters y early. 50.9 % of the subj ect worked in an urban area with a population base over 75,000. Overall, with the possible exception of the African American race grouping, the study has a good representation of Florida’s h ealthcare providers a nd the population as a whole. The Questionnaire The study questionnaire, with a response rate of 25%, is relatively comparable with other studies using a mail/web survey (72) The choice of an email/ web survey was beneficial to the researcher because it was less expensive than a traditional mail survey, it was time efficient for both the researcher and the subject s, it successfully prevented transcription errors, and it al lowed for real-time monitoring. The difference in cost of the web based survey versus the traditional survey was tremendous. The study by Couper in 1999 showed no significant cost be nefit of an e-mail survey compared with a trad itional mail survey (61). He suggested that the cost in constructing e-mail surveys required more th an 150 hours and approximately cost $1.74 per completed case, while the cost of posta ge-mail was $1.81 per reply. For this study,

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119 the researcher, using an availa ble online software service ( www.questionpro.com ), took approximately 3 hours to conv ert the survey from a pape r format to the web based format. This survey’s total cost per re spondent was less than 5¢ each ($109.95, labor $60 and 1 month software lease $49.95). Using the $1.81 figure suggest ed by Couper, this bioterrorism survey would have cost a mini mum of $4,123.18 USD by postage-mail. This calculation does not include th e 22,800 invitations sent (50¢ each) and the increase in postage stamps since 1999. The use of the email/ web model survey in strument also prov ed to be a time efficient method for surveying Florida’s healthcare providers The survey was completed in 7 days from start to finish, with most of the subject respondi ng within days 1-3. A reminder was sent out at midnight on day 3 to all study subjects, whic h allowed a surge in responses on day 4 and 5. The two other planne d reminders were not sent out because the study received the required number of responden ts early on, and the researcher did not want to give the impression of “spam” emails to the subjects whom had already completed the survey. For the subjects, the survey was also more time efficient because the technique of branching wa s utilized. This allowed subj ects to jump non-applicable questions within the survey base d on their previo us answer. The data was recorded electronically, whic h reduced transcription errors to zero. While data quality based on the percentage of respondent s who missed at least one questionnaire item is controve rsial, it was suggested by Paol o et al. that the traditional mail survey had a lower rate of incomplete returned questi onnaires compared with the email survey, 27% vs. 9%. (75). This wa s not the case in this study with an 85.7% completion of all questions.

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120 Finally, mail/web survey perm itted the researcher to m onitor the survey in realtime, allowing constant updates of the number of individuals who we re currently taking the survey, and the number who exited without completion and successfully completed it. The only real down sides are lower respons e rate because the researcher allowed only 1 week completing the surv ey and did not allow second at tempt, if the first attempt was incomplete. The uncompleted survey may have been a factor related to the busy schedule of healthcare provide rs that could not finish the survey in one sitting. Additionally, in the months following th e survey closure, 100s of providers continued to visit the site and to reply to th e invitation email, seeki ng to take the survey or view the results from the su rvey. This suggests that th e research topic is one of concern to the healthcare provi ders within Florida and that the response rate could have been much higher. The Assessment of the Providers Competency Levels The assessment of the providers’ competency levels was the core component of this study. This assessment of the competenci es should provide Flor ida with a better understanding of its current prov ider preparedness levels and what areas the needs to be focused upon for improvement. The Individual Core Competencies Within this study, the core bi oterrorism competencies we re used to evaluate the provider’s administrative skil ls and the clinical knowle dge. Each of these core competencies represents an individual base knowledge area that is deemed necessary to have to be minimally prepared to identi fy and manage a biot errorist attack.

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121 The eight administrative co mpetencies should be very basic, such as using communication equipment (i.e. fax), and knowing one’s role in a biot errorism response. It is not specialized knowledge such as the ability to mana ge a nuclear incident response or being able to disarm a di rty bomb. These would be consid ered advance skills for the average provider and not set at a core level for his/her job descrip tion. This is a very common mistake when governmental agencies and private entities ar e developing and/or adjusting the core competency sets for it organizations. This is because many of the administrative core competencies seem to be too basic at first glance, as with AC3, the correct use of communications equipment, such as phones, radios, and fax machines. Nevertheless, it was found that only 72.7% of the Florida’s providers had an acceptable competency level in this ar ea. This means if one of t hose 27.3% healthcare providers needed to report a possible bioterrorism attack and could not operate the basic communication equipment, this woul d possibly place lives in jeopardy. The clinical core competencies, while sti ll basic knowledge, are more related to the healthcare providers’ clinical ability to identif y and manage a bioterro rism attack. These included such knowle dge areas as being able to describe his/her exp ected clinical role in a bioterrorism response ( 73.9%) and the ability to recognize and manage the psychological impact of a biot errorism event (46.1%). Overal l, the individual clinical competency (CC1-8) scores are much lower than the administrative competency (AC1-8) scores. The results of this st udy revealed that Florida’s pr oviders’ un-weight ed CC (1-8) average is only 44.2% (physicians 48.9% nurses 44.9%, and pharm acists 37.0%) and the un-weighted AC(1-8) average is 61.2 % (physicians 59.1%, nurses 65.2%, and

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122 pharmacists 54.9%). The indivi dual strength and weaknesse s by provider type can be examined in Chapter 4, Results. The Administrative Competency Level and Clinical Competency Level The Administrative Competency Level (ACL) and Clinical Competency Level (CCL) are the weighted averages of administrative competencies and the weighted averages of the clinical competencies, respectively. The use of the weighted scores helped to adjust the importance of a knowledg e area (see Chapter 3, Methods for details). For example, AC3, the use of a fax is not rated by experts as important as the AC9, creative problem solving. The results from th is study reported that the ACL average was 62.8% and the CCL average was only 44.9%. These weighted scores increased the ACL for 61.2% un-weighted to 62.8% weighted and the CCL from 44.2% un-weighted to 44.9% weighted in this study’s sample. Within another setting (i.e health department employees, hospital, or State of Alabama), these adjustments of the individual scores may greatly increase or decrease the ACL and CCL scores. The Bioterrorism Competency Level The bioterrorism competency level (BCL) is used to score the overall competency level of the individual and th e grouping as a whole. The BCL looks at only the weighted knowledge (competency level) of the providers, not the overal l preparedness levels. The BCL in this study was 51.1%. This suggests that only 51% of Florida’s community healthcare providers have the minimum bioterrorism competen cy level to identify and manage an event without hurting themselves and/or others.

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123 These results of the BC L should convince the FDOH to move some of its bioterrorism training and exer cise dollars away its profes sional emergency planners / coordinators, to the community’s healthcare providers. The biot errorism trainings developed over the past two years by FDOH various Florida unive rsities and the other contracted entities, have all been presented at an awareness level. There have been little, if any operational level training conducted. These types of trai nings, hopefully, do not better prepare the FDOH emergency planner/ coordinator. These planner/ coordinators should already possess awareness level knowle dge prior to being hired. With only awareness training, it would be correct to say that the emer gency planner/ coordinators would be very aware of an at tack, but would not know what to do to correct the issue. Unlike hurricanes, where the FDOH responds after the impact of the event, a bioterrorism attack is ongoing and the thr eat may or may not be pres ent during the response. The emergency planners / coordinators, along w ith the executive st aff (county health department directors), will not be able to us e its standard practice of working thought the event, learning as you go, wit hout endangering the health a nd safety of themselves and the population. On the other hand, the admini stering of awareness training to community health providers would greatly increas e the preparedness levels of the community healthcare providers and possible encourage the format ion of a volunteer gr assroots health care emergency response system (provider volunteer s), and also increase enrollment of the Florida’s Medical Reserve Corps (MRC). Thes e providers will be n eeded to successfully activate the county emergency management plans during a bioterro rism event and/or mass casualty incident. The resu lts of this study suggested th at providers who have had

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124 previous trainings (beta= .1049, p=.000) and/or drills (bet a = .941, p=.000) were over 2.5 times more likely to be prepared than providers not trained or drilled. The Assessment of the Provid ers Willingness to Respond The assessment of the provide rs’ willingness to respond wa s also a core component of this study. This assessm ent of the provider’s willi ngness to respond to various proximities across Florida and to different levels of risk (hig h risk / low risk, defined in Chapter 3, Methods) should provide Florida with a better un derstanding of its current preparedness levels and more over, to provide a more accur ate estimate of the expected volunteer provider levels duri ng an event. These provider estimates will hopefully be used for pre-incident planning of personne l expectations of pr ojected large scale emergencies. This study results suggested th at most Florida providers were willing to respond to both a high risk (HR) event and a low risk (LR) event within th eir local community (81.7% and 82.8%, respectively, se e Chapter 4, Results). In the Alexander and Wynia’s study (2003), it was suggested that physicians were willing to respond 80% of the time in a lower risk environment, 40% in a higher risk environment and 33% in the highest risk environment.(45) Florida physicians however, reporte d that 84.5% would respond to a HR event and 83.6% would respond to a low LR event within th eir local community. This elevated willingness to respond score in HR events could possibly be explained by the proximity factor. In the Alexander and Wynia study, no proximity was expressed. When a disaster affects your friends, family and neighbors, physicians may be more willing to help, even when the risk is higher In contrast, when Florida physicians were

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125 asked if they were willing to respond to biological agen t attacks outside their local community, only 53.6% of all subjects reported that they are willing to respond to a HR event. While it is still much higher than the previous study, the physicians’ willingness level dropped over 20 percent points. The remaining gap in the di fferences may be explaine d by the providers seeking out bioterrorism traini ng activities and/ or pa rticipating in drills and exercises since 2003. The results from this study indicate that previous trainings (beta = .286, p=.010) and drills (beta = .436, p=.000) were significant pr edictors of the willingness to respond. So, it is suggestive that healthcare providers that had attended bioterro rism drills were 1.55 times more likely to be willing to respond to a bioterrorism at tack compared with providers who have never partic ipated in drills, or if that healthcare provider has had a previous emergency preparedness training, they were 1.33 times more likely to be willing to respond to a bioterrorism attack co mpared with no previous trainings. It was also found that providers under 24 (66.7%) and between the ages of 55-64 (59.6) were the most willing to respond to a statewide even t. Females (54.5%) are more willing than males (53.7%). American I ndians (n=7, 83.3%) and African Americans (65.9%) were more likely to respond than Caucasians (52.8%) and Asian/ Pacific Islanders (53.7%). Providers w ith associate degrees (59.1%) ar e more likely to respond than providers with doctorate degrees (53.7 %) and the foreign ed ucated (n=10, 50.0%). Providers with a primarily work place in a clinic setting (60.4%) and non-teaching hospital (56.4%) are much more like to res pond than providers that work in the home health care setting (40.9%) or in a university/res earch setting (41.9%).

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126 The researcher’s main concer n over these statistics was th e lack of willingness to respond by the majority of the pr oviders that are as signed to care for the sick in their homes (home health setting, 40.9%). This is a legal requirement of provider companies that have licensed home health companies within the state. Th is has been an ongoing issue during other emergencies, such as hurricanes / flooding with th e activation of the special needs shelters. At th e time of the study, this i ssue was awaiting address by the State legislature. Home health agencies do not want to be required to provide care for their patients during the time of emergencies, and for their patient s at special needs shelters. This issue, which is not normally addressed in the CEMP, should be addressed or corrected. The willing to respond to a statewide event was used in the calculation of the overall providers’ preparedness level. The statewide calculation was used because the boundaries are more defined than the local community and in an event of a large scale event, as Florida’s Strategic National Stockp ile plans are written, it will take providers from across the state to activ ate the plans and treat th e patients effectively. The Assessment of the Providers Overall Preparedness Level (PL) The overall bioterrorism preparedness le vel of the public heal th system, FDOH and the community healthcar e providers has been in questi on since the 2001 anthrax attacks. If the physician, w ho reported the 1st case of inhalation anthra x in Florida, did not recognize the symptoms (competency), and wa s not willing to be proactive throughout the response (willingness to response), the outcome would have been much worse. The calculation of the bioterrorism preparedness level (PL) was the final step within the study’s con ceptual framework. It combined the providers’ bioterrorism

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127 competency level (BCL) and their willing to respond to a statewide event by matching individual providers scores. To be deemed prepared, the provider must be willing to respond at least 50% of the time and have a BCL greater than 50%. When the WTR and BCL were examined separately, the providers’ WTR to a statewide event was 53.7% and their BCL was 51.1%. But wh en the WTR and BCL were Matched, the PL scores dropped to 32.2% for the community providers (physicians 34.6%, nurses 38.4% and pharmacists 17.4%, see Figu re 4-5). This indi cates that 32.2% of Florida’s community health care providers had both the min imal level of competency to effectively function without endangering him/herself and others, and are willing to respond to a bioterrorism attack within the St ate of Florida. The nur ses were recognized as more prepared than the other subgroups du e to their skills in both the ACL and CCL. Physicians had the highest CCL but lacked the nurs es on the ACL. The pharmacist scored lowest in both the ACL and CC L. This may be due to their normal job functions and the perception of the not being a di rect clinical provider during an attack. So, the pharmacist may not perceived benefits of bioterrorism training and no t sought it out, which is a predictor for being prepared fo r bioterrorism attack. If a prov ider had participated in a training, he/she is 2.86 more time likely to be prepared than a provi der who has not been trained. The examination of the ACL, the CCL, the BCL and the WTR scores individually (as described above) are very beneficial in identifying areas to target for interventions and trainings. However, when the scores have been calcula ted and matched, this allows for a more accurate provider pr eparedness level. Providers ma y be willing to respond but lack the skills to function and, providers may be 100% competent in their skills, but never

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128 responds to the event. In the ons et of the event, it is more important to be competent in identifying the attack (compete nt). Once the event is ongoing, it is more important to be willing to respond. Both roles should be ad dressed when looking at the providers’ preparedness levels. It was also found that, even though females were more willing to respond and had a higher competency level than males, male providers were 1.32 times more likely to be prepared for the bioterrorism attack than fema le. This is explained by the fact that the females, who were competent, were not w illing to respond and, the females that were willing to respond were not as competent. In a earlier nationwide survey, only 25 percent of family physicians felt prepared to respond to a bioterrorist event in 2001 (5 ) and again in 2002, only 21 percent of the physicians surveyed, felt personally well pr epared for a bioterrorism attack (45). In comparison, the findings of this study suggest that 55.5% of Florida’s community healthcare providers do NOT feel prepared and 41.5% feel so mewhat prepared to identify and manage a bioterrorism atta ck (see Figure 4-6). Only 3.0 of Florida’s providers feel very prepared. Since the personal percepti on of individual prep aredness, “feeling” prepared, was defined by the subject, this st udy can only be generally compared (feeling prepared or feeling not prepared) to the 2001 and 2003 surveys. While 75% of the surveyed provider did not feel prepare in 2001, and 79% of the surv eyed did not feel prepared in 2002, this 2005 survey of Florid a’s providers suggest that only 55.5% do not feel prepared. This increase in perceived preparedness levels, the “feeling” of being prepared, suggests that providers have more current confidence in their knowledge base and clinical skills. This coul d be a direct result of bioterrorism tr ainings and drills

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129 received or the fact the issue of bioterrorism is less preval ent in society, than in 2001 and 2002. List of Study Limitations 1. This study only surveyed providers that had an active email listed. 2. The selection of the subjects was base d on the e-mail li sted in a public database of licensed healthcare providers The lists might not be completed or updated, e.g., number of members, e-ma il addresses, current job setting. This might results in the eliminations of some po pulations from the study, who were listed as working in the institutional settings (hospitals), but actually they work in the comm unity setting. 3. Although the researcher revi ewed the e-mail lists clos ely and corrected most of obviously incorrect e-mail addresses in the lists, the errors remained and cannot be corrected by the researcher. This issue posted a problem of high undelivered e-mails with th e invitation letters. 4. The number of questionnaire s that should be sent out to obtain the required sample size for statistical power was calculated for each healthcare profession based on the same response rate. Th e response rates of electronic surveys might be different among h ealthcare professions. Ho wever, the researcher decided to use the same rate, but conser vative (low response rate), across the selected professions. 5. The responses may have been influenced by a socially desirable bias in this time of War on Terror.

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130 6. Even though the ques tionnaire obtained a response rate similar to other web based surveys, African Americans may have no t received appropriate representation within the study. 7. The administrative, clinical and social demographic characteristics that was recognized, only explained a small variance for the subject overall preparedness levels and willingness to respond. The defining characteristics of a bioterrorism response by healthcare providers are mu ltifaceted and complex. 8. The researcher is not able to identify whether the non-responders were similar to the responders or not. It is difficult to eliminate response biases. For example, the responders might be th e subjects who were interested or involved in preparedness of bioterrorism events. 9. The Bioterrorism Preparedness Model and the questionnaire were designed to fulfill the study’s obj ectives. Further statistical va lidation of the Bioterrorism Preparedness Model and the questionnaire is continuing.

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131 Conclusion and Implications This study was motivated by the recognized threat of bioterrorism attack upon Florida’s population and the un certainty that the planning ef forts by the State of Florida since 2001 could be operationali zed during a biological terroris m attack. It has been able to determined Florida’s community healthcare providers’ overall preparedness levels and by provider subgroups, and to sugg est the key factors that in fluence these levels. This study also determined the willi ngness of the provider to respond to a bi oterrorism attack within the State of Florida at va rious proximities and risk levels. The conceptual framework wa s created to serve the study’ s objectives. It consisted of three domains, the first two were based on the core competency sets (administrative and clinical) whose development was spons ored by the CDC and used by numerous entities across the nation, a nd the third is the providers’ willin gness to respond. This framework also included a me thodology to calculate the bi oterrorism competency and preparedness levels based on the importance of several leading experts in the field of public health preparedness at the time of this study. Th is was the first study that attempted a methodology to actually measur e the provider’s preparedness levels, and to examine physicians, nurses and pharmacist as a single provider gr ouping. Past provider studies have mainly examined physicians or nurses, but in a real event all licensed providers will be called upon. The study’s results are usef ul identifying critical areas for bioterrorism preparedness training and education, and the improving of biote rrorism planning and preparedness. The conceptual framework and its measurements, can be used to benchmark between provider groupings, between states and between organizations of all sizes. It also could be used as a base lin e of preparedness levels, which can be used to

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132 document changes over set periods of time. These changes can be used to monitor whether interventions are successful and ju stify the continuation of federal funded projects. Finally and most important, this study can guide emergency planners/ coordinators better project in the pre-disaster ph ase, the number of h ealthcare providers that are willing and able to res pond to a bioterrorist attack.

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133 REFERENCE LIST (1) Garrett LC, Magruder C, Molgard CA Taking the terror ou t of bioterrorism: planning for a bioterrorist event from a lo cal perspective. J Public Health Manag Pract 2000; 6(4):1-7. (2) Inglesby TV, Grossman R, O'Toole T. A plague on your ci ty: observations from TOPOFF. Clin Infect Dis 2001; 32(3):436-445. (3) Khan AS, Morse S, Lillibridge S. Public-health preparedness for biological terrorism in the USA. La ncet 2000; 356(9236):1179-1182. (4) Wetterhall SF. Public health prepar edness for bioterrori sm. J Med Assoc Ga 2002; 91(2):8-11. (5) Chen FM, Hickner J, Fink KS, Galliher JM, Burstin H. On the front lines: family physicians' preparedness for bioterro rism. J Fam Pract 2002; 51(9):745-750. (6) Alibek S, Handelman S. Biohazard: The chilling true story of the largest covert weapons programs in the world. 1999. New York, Random House. (7) Secretary of St ate Madeline Albright. Patterns of Global Terrorism 2000. Washington, D.C., U.S. De partment of State. (8) Okumura T, Suzuki K, Fukuda A, Koha ma A, Takasu N, Is himatsu S et al. The Tokyo subway sarin attack: disaster management, Part 1: Community emergency response. Acad Emerg Med 1998; 5(6):613-617. (9) Asai Y, Arnold JL. Terrorism in Japan. Prehospital Disaster Med 2003; 18(2):106-114. (10) U.S.Senate. Report of the U.S. Senate Select Committee on Inte lligence and U.S. House Permanent Select Co mmittee on Intelligence Together with Additional Views. S.Rept.No.107351 107th Congress, 2d Session H.Rept.No.107-792 121-2002. (11) Tom Mangol d, Jeff Goldberg. Plague Wars: The terrifying reality of biological warefare. 1 ed. New York: St. Martins Press, 2000. (12) Geneva Convention Reprint. Convention on the Prohibiti on of the Development, Production and Stockpiling of Bacteriol ogical (Biological) and Toxin Weapons and on their Destruction. 4-10-1972.

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134 (13) Office of Tec hnological Advancement. Proliferation of weapons of mass destruction: Assessing the risks. [Publication OTA-IS C-559]. 1993. Washington, D.C., U.S. Government Printing Office. (14) Wang BC, Turndorf H. Prevention of medication error. N Y State J Med 1981; 81(3):395-402. (15) Khan AS, Ashford DA. Ready or not? preparedness for bioterrorism. N Engl J Med 2001; 345(4):287-289. (16) Becker S, Beitsch L, Bialek R, Fi elding J, Gilchrist M, Hamburg M et al. Ready or Not? Protecting the Public's Health in the Age of Biote rrorism. 2003. Trust for America's Health. Issue Report. (17) Dade County Health Department. Strategic National Stockpile Plan 2004. (18) EREC. Strategic National Stockpile Plan Template. 2004. (19) Hillsborough County Health Department. Strategic National Stockpile Plan 2004. (20) Pasco County Health Department. Strategic National Stockpile Plan 2004. (21) Polk County Health Department. Strategic National Stockpile Plan. 2004. (22) Kristine M.Gebbie. Bioterrorism and Emergency Read iness: Competen cies for all Public Health Workers TS 0740. 2002. Center of Disease Control. (23) Agency for Healthcar e Research and Quality. Small pox (Extensive Information). http://www.bioterrorism.uab.ed u/EIPBA/Smallpox/smallpox.html 10-15-2001. (24) Center for Di sease Control. Strategi c National Stockpile. http://www.bt.cdc.gov/stockpile/ 8-11-2004. (25) Gullion JS. School nurs es as volunteers in a biot errorism event. Biosecur Bioterror 2004; 2(2):112-117. (26) Sibbald B. Right to refuse work becomes anothe r SARS issue. CMAJ 2003; 169(2):141. (27) Eitzen E, Takafuji E. H istorical overview of biological warefare. In: Sidell F, Takafuji E, Franz D, editors. Medical Aspects of Ch emical and Biological Warefare. Washington, DC: TMM Publications, 1997: 415-423. (28) Gwerder LJ, Beaton R, Daniell W. Bi oterrorism. Implications for the occupational and environmental health nurse. AAOHN J 2001; 49(11):512-518.

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135 (29) O'Connell KP, Menuey BC, Foster D. Issues in preparedness for biologic terrorism: a perspective for critical care nursing. AACN Clin Issues 2002; 13(3):452-469. (30) Smith CG, Veenhuis PE, MacCormack JN. Bioterrorism. A new threat with psychological and soci al sequelae. N C Med J 2000; 61(3):150-163. (31) Davis CJ. Nuclear blindness: An over view of the biological weapons programs of the former Soviet Union and Iraq. Emerg Infect Dis 1999; 5(4):509-512. (32) U.S.Depar tment of State. Convention on the Prohibiti on of the Development, Production and Stockpiling of Bacteriol ogical (Biological) and Toxin Weapons and on Their Destruction Bureau of Arms Control, editor. U.S.Department of State Website 1-12-2005. (33) Henderson DA. Biote rrorism as a public health threat. Emerg Infect Dis 1998; 4(3):488-492. (34) McDade JE, Franz D. Bioterrorism as a public health threat. Emerg Infect Dis 1998; 4(3):493-494. (35) Inglesby TV, O'Toole T, Henderson DA, Bartlett JG, Ascher MS, Eitzen E et al. Anthrax as a biological weapon, 200 2: updated recommendations for management. JAMA 2002; 287(17):2236-2252. (36) Persell DJ, Arangie P, Young C, Stokes EN, Payne WC Skorga P et al. Preparing for bioterrorism: category A agents Nurse Pract 2001; 26(12):12-24, 27. (37) Centers for Disease Control and Prevention. Bioterrori sm Agents/Diseases. Centers of Disease Control a nd Prevention Website 11-19-2004. http://www.bt.cdc.gov/ (38) Henderson DA, Inglesby TV, Bartlett JG, Ascher MS, Ei tzen E, Jahrling PB et al. Smallpox as a biological weapon: medi cal and public health management. Working Group on Civilian Biodef ense. JAMA 1999; 281(22):2127-2137. (39) Breman JG, Henderson DA. Diagnos is and management of smallpox. N Engl J Med 2002; 346(17):1300-1308. (40) Meselson M, Guillemin J, Hugh-Jone s M, Langmuir A, P opova I, Shelokov A et al. The Sverdlovsk anth rax outbreak of 1979. Sc ience 1994; 266(5188):12021208. (41) Kaufmann AF, Meltzer MI, Schmid GP The economic impact of a bioterrorist attack: are prevention and postattack in tervention programs justifiable?. Emerg Infect Dis 1997; 3(2):83-94.

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136 (42) Centers for Disease Control and Prevention. Preventing emerging infectious diseases: strategies for the 21st centur y. Overview of the updated CDC Plan. Morb Mortal Wkly Rep MM WR 47[RR15], 1-14. 1998. (43) Centers for Disease Contro l and Prevention. SNS Program Website. http://www.bt.cdc.gov/stockpile/index.asp 12-9-2004. (44) Beaten RD, Stevermer A, Wick lund J, Owens D, Boase J, Oberle MW. Evaluation of the Washingt on State National Pharmaceut ical Stockpile dispensing exercise, part II--dispensary site worker findings. J Public Health Manag Pract 2004; 10(1):77-85. (45) Alexander GC, Wynia MK. Ready and willing? Physicians' sense of preparedness for bioterrorism. Health Aff (Millwood ) 2003; 22(5):189-197. (46) Shadel BN, Rebmann T, Clements B, Chen JJ, Evans RG Infection control practitioners' perceptions and educational needs regard ing bioterrorism: results from a national needs assessment surve y. Am J Infect Control 2003; 31(3):129134. (47) Setlak P. Bioterrorism preparedne ss and response: emergi ng role for healthsystem pharmacists. Am J Hea lth Syst Pharm 2004; 61(11):1167-1175. (48) Setlak P. Bioterrorism preparedne ss and response: emergi ng role for healthsystem pharmacists. Am J Hea lth Syst Pharm 2004; 61(11):1167-1175. (49) Dr. Marc Yacht. 2004. Pe rsonal Communication. January 14, 2004. (50) Kristine M.Gebbie. Personal Communication via the Phone. 9-18-2003. (51) Glanz K., Lewis FM, Rimer BK. Health Behavior and Health Education 2 ed. San Francisco, CA: Jossey -Bass Publishers, 1996. (52) Montano D.E., Taplin S.H. The theory of Reason ed Action and th e Theory of Planned Behavior. Health Behavior and Health Edu cation 85-112. 1996. JosseyBass Publishers. (53) Ajzen I, Fishbein M. Understanding Attitudes and Pr edicting Social Behavior. Englewood Cliffs, NJ: Prentice Hall, 1980. (54) Fishbein M. The Theory of Reasoned Action: It s Application to AIDS Preventive Behavior Oxford, England: Pergamon Press, 1993. (55) Ajzen I. The theory of planned behavior. Organizational Be havior and Human Decision Processes 1991; 50:179-211.

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137 (56) Kendall JB, Hart CA, Pennefather SH, Russell GN. In fection control measures for adult cardiac surgery in the UK--a survey of current practice. J Hosp Infect 2003; 54(3):174-178. (57) Kim HL, Gerber GS, Patel RV, Hollowell CM, Bales GT. Practice patterns in the treatment of female urinar y incontinence: a postal a nd internet survey. Urology 2001; 57(1):45-48. (58) Thompson T, Sullivan F, Penny K. Th e Westdoc Internet Qu estionnaire--a survey of the use of "on-line" re sources by West Lothian gene ral practitioners Health Bull (Edinb ) 1999; 57(6):415-417. (59) Parker L. Collecting data th e e-mail way. Training and Development 1992;(July):52-54. (60) Zhang Y. Using the internet for survey research: a case st udy. Journal of the American Society for Info rmation Science 2000; 5:57-68. (61) Couper M.P., Blair J ., Triplett T. A comparison of ma il and e-mail fo r a survey of employees in U.S. Statistical Agencies. Journal of Official Statistics 1999; 15:3956. (62) Jones R., Pitt N. Health surveys in the workplace: comparison of postal, email and World Wide Web methods. Occu pational Medicine 1999; 49:556-558. (63) Kittleson M.J. An assessment of th e response rate via the postal service and email. Health Valu es 1995; 18:27-29. (64) Mehta R., Sivadas E. Comparing response rates a nd response content in mail versus electronic ma il surveys. Journal of the Ma rket Research Society 1995; 37:429-439. (65) Schaefer D.R., Dillman D.A. Deve lopment of a standard e-mail methodology: results of an experi ment. Public Opinion Quarterly 1998; 62:378-397. (66) Schuldt B.A., Totten J.W. Electr onic mail vs. mail surv ey response rates. Marketing Research 1994; 6:36-44. (67) Tse A.C.B. Comparing the response rate, response speed a nd response quality of two methods of sending questi onnaires: e-mal versus mail. Journal of the Market Research Societ y 1998; 40:353-361. (68) Jepson C, Asch DA, Hershey JC Ubel PA. In a mailed physician survey, questionnaire length had a threshold effect on respons e rate. J Clin Epidemiol 2005; 58(1):103-105.

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138 (69) Hassol A, Walker JM, Kidder D, R okita K, Young D, Pierdon S et al. Patient experiences and attitudes a bout access to a patient elect ronic health care record and linked web messaging. J Am Med Inform Assoc 2004; 11(6):505-513. (70) Wu JM, Hundley AF, Visco AG. Electiv e primary cesarean de livery: attitudes of urogynecology and maternal-fetal medicine specialists. Obstet Gynecol 2005; 105(2):301-306. (71) Seguin R, Godwin M, MacDonal d S, McCall M. E-mail or snail mail? Randomized controlled trial on which works better for surveys. Can Fam Physician 2004; 50:414-419. (72) Chonlau M., Fric ker R.D.Jr., Elliott M.N. Literature review of web and e-mail surveys. Conducing research su rveys via e-mail and the web. RAND Publications, 2001: 19-32. (73) Bachman E., Elfrink J, Vazzana G. Tracking the progr ess of e-mail vs. snail-mail. Marketing Research 1996; 8:31-35. (74) Comley P. Internet su rveys: the use of th e internet as a data collection method. ESOMAR/EMAC: Research Methodol ogies for "The New Marketing" symposium 1996; 204:335-346. (75) Paolo A.M., Bonaminio G.A., Gibson C., Partridge T ., Kallail K. Response rate comparisons of e-mail an d mail distributed studen t evaluations. Teaching and Learning in Medici ne 2000; 12:81-84. (76) Kiesler S., Sproull L.S. Response effe cts in the electronic survey. Public Opinion Quarterly 1986; 50:402-413. (77) Tse A.C.B. Determining effective foll ow-up of e-mail surveys. American Journal of Health Behavior 1997; 21:193-196. (78) Chonlau M., Fricker R. D.Jr., Elliott M.N. Literature review of web and e-mail surveys. Conducing research surveys via e-mail and the web. RAND Publications, 2001: 19-32. (79) Terry E.Hedrick, Leonard Bickman, Debra J.Rog. Applied research design : a practical guide. Newbury Park: Sage Publications, 1993. (80) SPSS for Windows. 11.5 2005. www.spss.com

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139 APPENDICES

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140 APPENDIX A QUESTIONNAIRE FLORIDA HEALTH CARE PROVIDER BI OTERRORISM PREPAREDNESS SURVEY Welcome!! I am asking for your help as a part of a survey I am conducting regarding Florida health care providers’ Bioterrorism prep aredness levels and their willingness to respond. COMPLETING THE ONLINE SURV EY: Please plan on taki ng about 15 minutes to complete the following survey. You must comp lete the survey in one sitting. You will not be able to go back to previ ous questions or to change answ ers. When you have completed the survey, please click on th e button that says “continue .” Your candid answers are important to ensure an accurate assessm ent of Florida’s health care provider’s bioterrorism preparedness levels. Please answ er the questions on your own and to the best of your ability, without us ing any resources (books, websites, co-workers). CONFIDENTIALITY: Your partic ipation in this survey is strictly confidential. No information about you, or provided by you, will be disclosed to others. No personal data (i.e., Name, Address, Employer Name) will be co llected in the surve y. The identities of individuals who complete the su rvey and their results will be kept confidential. Individual results will not be re leased. Any reports, publications, or other materials developed from results of this survey wi ll not contain any identifyi ng information about you.

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141 APPENDIX A (CONTINUED) FURTHER INFORMATION: If yo u have any questions about this survey or how the information will be used, please contact Mr. Jeffrey Crane at 704-865-8902 or e-mail jcrane@jscrane.com. If you have questions regarding your right s as a research subject, please contact the USF Office of Research at 813-974-5570. Thank you for participating in this importa nt assessment surv ey. Your time and effort are grea tly appreciated! J.S. Crane, LLC 2004-200 5. All Rights Reserved To get permission to use, pl ease email Jeffrey Crane at: jcrane@jscrane.com or visit www.jscrane.com

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142 APPENDIX A (CONTINUED) Please select a single answer (Required) Question 1. What is your current AGE? Under 18 18 24 25 34 35 44 45 54 55 64 65 or older Please select a single answer (Required) Question 2. What is your GENDER? Male Female Please select a single answer (Required) Question 3. What is your RACE? Caucasian African American American Indian, Eskimo, or Aleut Asian or Pacific Islander Hispanic Other

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143 APPENDIX A (CONTINUED) Please select a single answer (Required) Question 4. What is the HIGHEST EDUCATI ONAL DEGREE that you have completed? Associate's degree Bachelor's degree Master's degree Doctorate (DO, Ph.D, MD, PharmD, DDS) Foreign Educated (Please Specify) Please select a single answer (Required) Question 5. How many years have you worked as a licensed professional? Less than 1 year 1 to 2 years 3 to 5 years 6 to 10 years 11 to 20 years Over 20 years I have NOT WORKED as a licensed professional. Please select a single answer (Required) Question 6. Which of the following BEST represents your current position? MDMedical Doctor DODoctor of Osteopathy NPNurse Practitioner RNRegistered Nurse RPhRegistered Pharmacist Pharm.D.Doctor of Pharmacy Other (Please Specify)

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144 APPENDIX A (CONTINUED) Please select a single answer (Required) Question 7. I am currently: Employed in a Healthcare Setting Not Employed in a Healthcare Setting Unemployed Retired Please select a single answer (Required) Question 8. What is your PRIMARY work place? Hospital, none Teaching Teaching Hospital Long-term Care, none Home Healthcare Home Healthcare Private Single Practice Private Multi-Physician Practice Clinic Setting Institutional Pharmacy (Hospital and Long-term Care) Community Pharmacy (Retail/Chain) University or Research Setting I am Retired. Other, Please Specify:

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145 APPENDIX A (CONTINUED) Please select a single answer (Required) Question 9. Average 2002-2003 patient encounter volume for your PRIMARY work place? Under 5,000 5,000 – 9,999 10,000 – 19,999 20,000 – 39,999 40,000 – 59,999 60,000 – 79,999 80,000 + Not Applicable

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146 APPENDIX A (CONTINUED) Please select all answers that apply (Required) Question 10. Services that YOU provide in your PRIMARY work place? (Please Check ALL That Apply): General Medicine ICU/CCU Mental Health Substance Abuse Pediatric Medicine Laboratory X-Ray Institutional Pharmacy Services (Hospital and Long-term Care) Community Pharmacy Services (Retail/Chain) Obstetrical Gynecology Inpatient Surgery Outpatient Surgery Emergency Room Services, none Trauma Trauma Center Services Home Health Care Services Public Health (Epidemiology and Immunizations) Long-term Care Nursing Service Teaching / Research I am Retired. Other, Please Specify:

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147 APPENDIX A (CONTINUED) Please select a single answer (Required) Question 11. Which of the following BEST describes the city or county where you work? Rural Urban Suburban Please select a single answer (Required) Question 12. Which of the following BEST describes the population size of the city or county where you work? Small City (Less than 25,000 persons) Medium City (25,000 to 75,000 persons) Large City (Greater than 75,000 persons) Please select a single answer (Required) Question 13. Does your organization have an Emergency Response/ Disaster plan? Yes NO, We do not have an Emergency Response/ Disaster plan. I Do NOT know. Please select a single answer (Required) Question 14. I know where the plan is located? Yes No Don't Know

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148 APPENDIX A (CONTINUED) Please select a single answer (Required) Question 15. I have reviewed the plan in the last 12 months? Yes No Don't Know Please select a single answer (Required) Question 16. I know my role according to the plan? Yes No Don't Know Please select a single answer (Required) Question 17. Did the Plan have a special organizational structure and organized leadership (e.g., incident command system) during a disaster or emergency? Yes No Don't Know Please select a single answer (Required) Question 18. Does the plan specifically address bioterrorism? Yes No Don't Know

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149 APPENDIX A (CONTINUED) Please select a single answer (Required) Question 19. Does the plan address emergency communications? Yes No Don't Know Please select all answers that apply (Required) Question 20. Please check ALL of the following statements that are TRUE. I am competent in the operation of a telephone. I am competent in the operation of a fax machine. I am competent in the operation of a two-way radio. I am competent in the operation of a satellite phone. Please select a single answer (Required) Question 21. Have you participated in a disaster drill within the last 12 months? Yes NO I have not participated in a disaster drill within the last 12 months. Please select all answers that apply (Required) Question 22. Types of the disaster drills that you participated: (Check ALL that Apply) Biological agent exposure Bomb threat Chemical agent exposure Nuclear/radiology agent exposure Mass casualty Not Applicable Other (Please List)

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150 APPENDIX A (CONTINUED) Please select a single answer (Required) Question 23. Have you received training in disaster awareness, preparedness, and response? Yes NO I have not received training in disaster awareness, preparedness, and response. Please select a single answer (Required) Question 24. I received training within the last 12 months? Yes No Please select a single answer (Required) Question 25. My training included preparedness for chemical or biological terrorism events? Yes No Please select a single answer (Required) Question 26. It was an annual “Refresher” training in disaster preparedness? Yes No

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151 APPENDIX A (CONTINUED) Please select all answers that apply (Required) Question 27. What type of training did you receive? (Check ALL that Apply.) Biological agent exposure Bomb threat Chemical agent exposure Nuclear/radiology agent exposure Mass casualty Other (Please List) Please select all answers that apply (Required) Question 28. When you participated in training for bioterrorism, which of the following teaching methods/ modalities were used? (Please check ALL that Apply) Traditional lecture Format (I.e., slides, handouts, videos, etc.) Online interactive (i.e., Discussion boards, tutorials, simulations, etc) Web-casts, teleconferences, or satellite broadcasts Self learn, self paced study (i.e., independent study courses) Other Please select a single answer (Required) Question 29. Generally Speaking, which SINGLE METHOD/MODALITY would you prefer for future bioterrorism content training? Traditional lecture Format (I.e., slides, handouts, videos, etc.) Online interactive (i.e., Discussion boards, tutorials, simulations, etc) Web-casts, teleconferences, or satellite broadcasts Self learn, self paced study (i.e., independent study courses)

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152 APPENDIX A (CONTINUED) Please select a single answer (Required) Question 30. Generally Speaking, in Self-learning content on bioterrorism, which would be the SINGLE BEST source for you? A Textbook Information packets Journal articles Brochures Video Pre-prepared PowerPoint Slides Online Resources Strongly Agree Agree Neither Agree nor Disagree DisagreeStrongly DisagreeQuestion 31. Bioterrorism attacks are a real threat within the UNITED STATES? Strongly Agree Agree Neither Agree nor Disagree DisagreeStrongly DisagreeQuestion 32. Bioterrorism attacks are a real threat within FLORIDA? Strongly Agree AgreeNeither Agree nor Disagree DisagreeStrongly DisagreeQuestion 33. Bioterrorism attacks are a real threat within your LOCAL COMMUNITY? Strongly Agree AgreeNeither Agree nor Disagree DisagreeStrongly DisagreeQuestion 34. My LOCAL medical community could effectively respond to a Bioterrorism attack?

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153 APPENDIX A (CONTINUED) Strongly Agree AgreeNeither Agree nor Disagree DisagreeStrongly DisagreeQuestion 35. I know my role as a health provider in a suspected Bioterrorism attack in my community? Strongly Agree AgreeNeither Agree nor Disagree DisagreeStrongly DisagreeQuestion 36. I know the “Chain of Command” for my work place in a suspected bioterrorism attack in my community? Strongly Agree AgreeNeither Agree nor Disagree DisagreeStrongly DisagreeQuestion 37. I know my WORK PLACE’S role in a suspected Bioterrorism attack in my community? Strongly Agree Agree Neither Agree nor Disagree DisagreeStrongly DisagreeQuestion 38. I know whom to call to report/refer a suspected bioterrorism attack?

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154 APPENDIX A (CONTINUED) Strongly Agree AgreeNeither Agree nor Disagree DisagreeStrongly DisagreeQuestion 39. I would recognize signs and symptoms of an illness due to bioterrorism in my own patients? Strongly Agree AgreeNeither Agree nor Disagree DisagreeStrongly DisagreeQuestion 40. I would recognize and treat the psychological effects to victims and healthcare professionals due to a bioterrorism attack? Strongly Agree AgreeNeither Agree nor Disagree DisagreeStrongly DisagreeQuestion 41. I know my limits in knowledge, skill, and authority in a suspected bioterrorism attack? Question 42. How important is it for your LOCAL HEALTHCARE SYSTEM to be prepared for a bioterrorism attack? Very Important Important Not Important At All Question 43. How important is it for YOU to be trained to identify a possible bioterrorism attack? Very Important Important Not Important At All Question 44. What is your current knowledge of the medical aspects of the DIAGNOSIS of bioterrorism related illnesses is: Poor Fair Good Very Good Question 45. What is your current knowledge of the medical aspects of the MANAGEMENT of bioterrorism related illnesses is: Poor Fair Good Very Good

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155 APPENDIX A (CONTINUED) Please select all answers that apply (Required) Question 46. From the list below, please choose ALL of the known bioterrorism agents/diseases? Tetanus (Tetanus) Bacillus Anthracis (Antrax) Bacterial Meningitis (Meningitis) Clostridium Botulinum Toxin (Botulism) Schistosomiasis (Schistosomiasis) Francisella Tularensis (Tularemia) Varicella Disease (Chickenpox) Yersinia Pestis (Plague) Parvovirus B19 Infection (Fifth Disease) Variola Major (Smallpox)

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156 APPENDIX A (CONTINUED) Question 47. Please READ the following Disease Description and CORRECTLY identify the disease from the list below? Bacillus Anthracis (Anthrax) Clostridium Botulinum Toxin (Botulism) Yersinia Pestis (Plague) Viral Encephalitis

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157 APPENDIX A (CONTINUED) Question 48. Which of the following Pictures CORRECTLY illustrates the typical pattern of smallpox rash distribution? (please do NOT look up!) Case A Case B Both Cases A and B None of the Above

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158 APPENDIX A (CONTINUED) Question 49. Examine the two sets of pictures of the rash of four different days (day 3, day 5, day 7 and day 10). Which set is Smallpox? (Please do NOT look up!) Set A (Red) Set B (Blue) Both Sets A and B None of the Above

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159 APPENDIX A (CONTINUED) INSTRUCTIONS: Please answer ALL the following questions as CANDIDLY as possible. (Please Note that a HIGH RISK event is defined as a bioterrorism agent that does NOT have a known treatment and/or vaccination.) QUESTION: How likely do you believe that YOU would respond to a bioterrorism event if your medical services were requested: Very Likely Somewhat Likely Neither Likely or Unlikely Somewhat Unlikely Very Unlikely Question 50. in a HIGH RISK event that affects YOUR COMMUNITY? Question 51. in a HIGH RISK event that affects a NEIGHBORING COUNTY? Question 52. in a HIGH RISK event that affects FLORIDA? Question 53. in a HIGH RISK event that affects the UNITED STATES? INSTRUCTIONS: Please answer ALL the following questions as CANDIDLY as possible. (Please Note that a LOW RISK event is defined as a bioterrorism agent that has a known treatment and/or vaccination.) QUESTION: How likely do you believe that YOU would respond to a bioterrorism event if your medical services were requested: Very Likely Somewhat Likely Neither Likely or Unlikely Somewhat Unlikely Very Unlikely Question 54. in a LOW RISK event that affects YOUR COMMUNITY? Question 55. in a LOW RISK event that affects a NEIGHBORING COUNTY? Question 56. in a LOW RISK event that affects FLORIDA? Question 57. in a LOW RISK event that affects the UNITED STATES

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160 APPENDIX A (CONTINUED) Please select a single answer (Required) Question 58. Do you "feel" prepared to diagnose and manage a bioterrorism attack? Very Prepared Somewhat Prepared Not Prepared Enter 5-Digits Only Question 59. Please enter your ZIPCODE.

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ABOUT THE AUTHOR Jeffrey S. Crane Jeff completed a BA degree from Appalachia n State University in 1995, the Masters of Public Administration degree from Troy State University in 1997, the Masters of Business Administration degree, and a Graduate Cert ificate in Disaster Management from the University of South Florida in 2002/2003. His military career include d service with the 11th Army’s Special Forces Group as an engineer/medic, and Naval service as a Corpsma n. Professional achievem ents have included the positions of ER Director of a hospita l, and the Director of a multimillion dollar pharmaceutical company in Washington, DC. Recen tly, he was an adjunct faculty member at the University of Florida’s (UF), Department of Pharmacy Administration. He is a Professor at the American Public University System, Department of Public Sector and Critical Infrastructure and teaches Emergency Planning for Western Carolina University in NC. Jeff has also worked as an Emergency Planner/ Coor dinator for the Florida Department of Health and Director, Pasco County Medical Reserve Corps. He is the President of J.S. Crane, LLC ( www.jscrane.com ).