The 2018 NYC Public Health Jurisdictional Risk Assessment

FINAL RESULTS

Françoise Pickart, Risk + AnalyticsDOHMH |Office of Emergency Preparedness and Response | December 2018

Goals of the JRA

• Identify and rank the top hazards to the public’s health in NYC

• Prioritize DOHMH preparedness work on the Response Inventory according to disaster risk

“…a robustness criterion often yields no single best answerbut rather helps decision makers to use available scientific and socio-economic information to distinguish a set of reasonable choices from unreasonable choices and to understand the tradeoffs implied by choosing among the reasonable options…”

Defining public health disaster risk

Hazard Occurs

(Probability)

This definition prioritizes a focus on consequences over severity alone.

Methods

5 Rounds of Surveys | May to October

• Round 1 Participants review current lists of hazards and contributors and suggest additions. Open-ended questions

• Rounds 2 & 3 Participants choose the top 9 from each list according to their relative importance. Choose 9

• Round 4 Participants weigh the relative importance of each contributor to disaster risk. Analytical Hierarchy Process

• Round 5 Participants rank hazards according to the relative influence of each contributor. Analytical Hierarchy Process

Participation by Stakeholder Group

DOHMH NYC Health Care Coalition

Total Participants

766

Also: 16 subject matter experts

from 13 universities/think tanks

Representing

100% of Divisions

99% of Bureaus

84% of Work Units

94% of ERGs

71% of ICS Leadership

Total Participants

709

Representing

50 Hospitals

132 Nursing Homes

NYC MRC

65 Other Health Care Orgs*

*Includes VA, OMH facilities, FQHCs, etc.

Other Government Agencies Non-Profits, Coalitions and Community Partners

Total Participants

110

Representing

27 NYC Agencies

11 NYS Agencies

3 Federal Agencies

Total Participants

231

Representing

142 total organizations

123 work with “at-risk”• 42 focus on people with disabilities

• 36 focus on immigrants

6680 surveys completed | 1832 participants

Public Health Hazards

• Cyber attack’s top spot driven by high probability and low manageability.

• Excessive heat is considered highly manageable but high probability puts it at #4.

• Low relative severity and high manageability put a MCI in last place.

Hazards for which we are least prepared

• Cyber Attack (Rank 1)

• Chemical Emergency (Rank 5)

• Air Contamination (Rank 8)

How do we measure the manageability of a hazard?

Response Inventory (what DOHMH does in emergencies)

→20 manageability contributors to evaluate

Round 1

→10 contributors added

30 manageability contributors evaluated

Final Manageability Contributors

See handout for full list

Round 5 Example

Pairwise comparison of hazards to create a prioritized list

Hazards that we are best able to manage

Final Severity Contributors

Severe injuries and an increase in illness.

15.5%

Deaths

15.0%

Risk of an associated disease outbreak

13.4%

Disruption to the potable water supply

12.1%%

Increase in harmful or life-threatening toxic exposures

and environmental contamination 10.0%

Loss of utility-provided power

9.7%

Diminished capacity of the healthcare system

9.2%

Food scarcity*

7.7%

Disruption of communications systems*

7.5%

*Contributors not used for ranking hazards as low weight would not affect outcome.

Hazards that are the most severe

How do we measure the probability of a hazard?

• Probability is the most difficult to measure element of risk.

• Four generic contributors chosen to estimate the probability across different hazard type.

Final Probability Contributors

Changes in the environment or threat landscape that make

it more likely to occur

38.0%

Forecast models and academic or actuarial studies

23.4%

An increasing frequency of similar events

23.2%

The number of reported occurrences

15.3%

Hazards that are most likely in the next 10 years

Hazards that didn’t make the final list

Emerging disease with epidemic potential and Large-scale release of a biological agent without

countermeasures were combined for ranking under Emerging Disease after Steering Committee review found the

two hazards were not sufficiently distinct. Both hazards represent an unknown threat with significant uncertainty.

Cut in Round 2

In order of votes

Cut in Round 3

In order of votes

Homelessness

Winter weather

Routine disease outbreaks

Mass incarceration

Civil disturbance

Earthquake

Obesity and metabolic syndrome

Space hazard impacts

Community violence

Radiological dispersion device

Food contamination

Large scale release of a biological threat

with available medical countermeasures

Nuclear explosion

“Choose the none hazards that you feel are the most critical for the city to focus its preparedness efforts on.

Not selecting one of these hazards does not mean it is unimportant to you, but it does mean it is of less concern

than those that you select.”

Hazards contributed by participants

Terrorism-focused hazards considered in the last JRA

• In the last decade, these hazards

have been focus of intense

planning resources.

• While these hazards remain a

threat, preparedness work has

reduced the disaster risk

considerably.

Top 3 Hazards

Respiratory Virus with Pandemic Potential

Facilitate at-risk populations’ access

to pharmaceutical countermeasures

to reduce disaster-related morbidity

and mortality

Conduct laboratory analysis of clinical,

environmental, food, and water samples

to identify specific threats

Activities we are best at in a Respiratory Pandemic

Activities we are worst at in Respiratory Pandemic

Manage

fatalities

Situational

awareness

Cohesive

citywide

response

Access to

resources

Vulnerable

populations

Increase law

enforcement

activities

Essential

services

Resources for

pets

Other FindingsManageability contributors critical to public health led by other agencies

NYCEM• Provide accessible transportation.• Provide temporary housing for those displaced from their home • Facilitating the rapid credentialing of medical personnel (w NYPD)• Connect available financial assistance to those impacted by the

disaster• Provide resources for pets• Provide technical assistance so community groups can better respond

(w DOHMH)• Provide mechanisms for two-way communications (w DOHMH)

NYPD• Increase law enforcement activities

OCME• Manage fatalities

Why this is a model for the nation

• Inclusive. First-of-its-kind public health risk assessment with meaningful input from

four communities:

Public Health - Health Care Sector - Government Partners - Community Groups

• Focuses on consequences not hazards. Instead of a traditional scenario analysis

approach, focuses on the health consequences of disasters and incorporates

scenarios with unidentified causes. Fits within a broader public health framework

tying risk estimates to the social determinants of health.

• Operational. Results produce a ranked list of critical activities to guide public health

preparedness work. Identifies gaps in City efforts that DOHMH can help address.

• Transparent and replicable. Decision making is transparent and tied to a public

health evidence base. Entire process is accessible, scalable and replicable.

Changing the risk paradigm

Traditional Risk Management A Resilience Approach to Risk JRA Approach

Principles Preservation of the status quo, that is, to

avoid transformative change; minimize the

risk of failures.

Adaptation to changing conditions without

permanent loss of function (e.g. changing paths if

not destinations).

Acknowledgement of unknown hazards.

Objectives Minimization of probability of failure, albeit

with rare catastrophic consequences and long

recovery times.

Minimization of the consequences of failure,

albeit with more frequent failures and rapid

recovery times.

Strategies Armoring, strengthening, oversizing,

resistance, redundancy, isolation.

Diversity, adaptability, cohesion, flexibility,

renewability, regrowth, innovation, transformation.

Mechanisms for

coordinating

response

Centralized hierarchical decision structures

coordinate effects according to response

plans.

Decentralized, autonomous agents respond to local

conditions. (able to identify areas for community)

Modes of

analysis

Quantitative (probability-based) and semi-

quantitative (scenario-based) analysis of

identified hazards in context of utility-theory

(i.e. costs and benefits)

Possible consequence analysis involving

scenarios with unidentified causes.

Park et al. Integrating Risk and Resilience Approaches to Catastrophic Management in Engineering Systems. 2013. Risk Analysis.

Reporting | 2019 Hazard Mitigation Plan

Public Health Jurisdictional Risk Assessment

DOHMH

Hazard Mitigation Plan 2019

NYCEM

Chemical Emergency CBRN

Coastal Storm or Nor’Easter Coastal Storm

Cyber Attack Cyber Threat

Emerging Disease with Epidemic Potential CBRN

Excessive Heat (includes power outages) Extreme Heat

Respiratory Virus with Pandemic Potential CBRN

Air Contamination (New)

Mass Casualty Incident

Water Contamination

Not in HMP

Not in JRA Coastal Erosion

Earthquakes

High Winds

Winter Weather

CBRN

Next Steps

1 DOHMH will use results to prioritize preparedness work across the agency.

December 2018

2 Report results in NYCEM’s 2019 Hazard Mitigation Plan

April 2019

3 Develop reports for 5 audiences:

• National audience

• DOHMH-focused report

• Government partners

• Health Care Sector

• Community partners

June 2019

Extra Slides

Methods

Measuring the Severity, Probability and Manageability of Hazards (Round 5)

• To measure severity contributors for the top hazards:• We surveyed DOHMH programs and external agencies that work in the

contributor area.

Example: OVS and OCME for Deaths

• To measure probability contributors for the top hazards:• We surveyed a broad swath of analysts with experience synthesizing

various data sources to make estimates.

• To measure manageability contributors for the top hazards:• We surveyed DOHMH Emergency Response Groups and external agencies

that perform the functions.

A Steering Committee with representatives from DOHMH, NYCEM and

ORR periodically reviewed the JRA process.

Top 3 Hazards

Cyber Attack

Activities we are best at in a Cyber Attack

Protect the safety of Health Department

personnel and coordinate public health

guidance for city workers

Activities we are worst at in a Cyber Attack

Risk

communications

Cohesive

citywide

response

Adequate

staffing

Access to

resources

Vulnerable

populations

Assist the

healthcare

system

Situational

awarenessEquity

Assist

community

groups

Track the

effects

Share data

Information

to

healthcare

providers

Essential

services

Knowledge

among

Health Dept

staff

Top 3 Hazards

Coastal Storm

Facilitate access to resources to

support the public health disaster

response

Connect available financial

assistance to those impacted

by the disaster

Create widespread knowledge among

Health Department staff of the

disaster-related health impacts and

related guidance

Provide resources for pets

Activities we are best at in a Coastal Storm

Activities we are worst at in a Coastal Storm

Two-way

communications

Laboratory

analysis

Safety of

Health Dept

staff

Accessible

transportation

Health policies

Prevent the

spread of

disease

Adequate

staffing