Hawaii Emergency Management Structure

Statewide: The Hawaii Emergency Management Agency (HI-EMA), located in the state Department of Defense, is the emergency management agency for the State of Hawaii. The Governor has direct authority over HI-EMA which serves as the coordinating agency for all county emergency management agencies, federal emergency management agencies, state departments, the private sector, and nongovernmental organizations.

HI-OEP: HI-EMA develops and maintains the State of Hawaii Emergency Operations Plan (HI-EOP), which is an all-hazards plan that establishes the shared framework for the state’s response to and initial recovery from emergencies and disasters. State agencies responsible for providing emergency assistance are organized into 16 functional groups, state emergency support functions (SESF). Each SESF outlines responsibilities of state agencies and partners for emergency functions and provide additional detail on the response to specific types of issues and incidents.

The last HI-EOP basic plan was completed in 2017 and was revised/updated several times through 2019 prior to the pandemic. By statute, the HI-EOP is updated every two years.

State Departments: Additionally, each state department has a EOP to address how each department will manage the impacts of an emergency on its operations and execute duties assigned by the HI-EOP.

Counties: Counties develop their own EOPs that is consistent with the HI-EOP and provides guidance on the utilization, direction, control, and coordination of local resources during emergency operations and address mechanism for requesting and integrating state support when local resources are not sufficient.

Department of Health (DOH). Within DOH, the lead for emergency management is the Office of Public Health Preparedness (OPHP) which is located directly under the Director of Health. OPHP works to prevent, mitigate, plan for, respond to, and recover from natural and human-caused health emergencies and threats. Prior to 2018, the OPHP was a branch under the Disease Outbreak Control Division (DOCD). However, this organizational location limited OPHP functions to disease-related emergency and response activities. The removal of OPHP from the DOCD allows the program to serve and support the entire Department, including Environmental Health, under the direct command of senior leadership for broad emergency response.

OPHP comprises 20 core staff, statewide and also funds positions at the State Laboratory and DOCD. OPHP also manages the state Medical Reserve Corps (MRC) that may provide volunteers to assist with emergency operations.

DOH in HI-EOP: In the HI-EOP, DOH has a lead role for SESF 8, Public Health and Medical and ESF 10, Oil and HAZMAT response. During a response, SESF representatives work with HI-EMA and other state, county and federal agencies to manage the incident.

DOH-EOP: The OPHP is responsible for developing and maintaining the DOH’s emergency operations plan (EOP). Plan review is conducted yearly following the end of the annual hurricane season based on lessons learned from real events and from exercises. The latest plan was completed in 2019 before the COVID pandemic. Title V was not directly involved in the plan development but is provided an opportunity for review and input.

Maternal Child Health (MCH): Both the HI-EOP and HI-DOH have limited language that specifically addresses the needs of maternal and child health. There is also minimal language for those with access and functional needs, which can include pregnant women and children. In the situational analysis, HI-EOP does acknowledge certain populations that are particularly vulnerable to the impacts of emergencies, including individuals with disabilities or access and functional needs and people with limited English proficiency:

• Individuals with disabilities and others with functional and access needs must be considered in emergency planning. Approximately 11% of Hawaii’s population has a disability. Nearly 50% of residents over the age of 75 are disabled
• Approximately 26% of residents speak languages other than English at home and 18% of the population is foreign born.

Incident Management Structure (IMS)

HI-EMA When an imminent or actual emergency threatens the state, HI-EMA coordintes the state’s response through the activation of the State Emergency Operations Center (SEOC) and the State Emergency Response Team. The Title V director served as the DOH EMSF-8 (Public Health & Medical) liaison to the SEOC prior and during the pandemic.

DOH During an emergency, the DOH establishes an emergency response structure to coordinate DOH’s activities using national IMS guidance – Department Operations Center (DOC). The OPHP trains DOH staff to fulfill leadership roles in the DOC for planning, operations, and logistics section chiefs as well as section staff. Members of the Family Health Services Division (FHSD) have been trained on, and served in, emergency management leadership roles before and during the pandemic as Section Chiefs in the DOC.

Hawaii’s Title V Director has served as the DOC Planning Section Chief; while FHSD’s Administrative Officer has served as the DOC Operations Section Chief. As the pandemic has proceeded, Title V’s representation of the DOC has been revised to focus of COVID-related emergency response.

AMCHP Emergency Preparedness and Response Learning Collaborative (ALC)

In 2019, Hawaii was fortunate to participate in an AMCHP Emergency Preparedness and Response Learning Collaborative (ALC) opportunity to address the maternal and infant health population. A team was recruited for the collaborative including representatives from the Title V agency (CSHNB staff), OPHP, the DOH Planning Office; Hawaii’s Medicaid agency; and a University of Hawaii Public Health doctoral student. Initially, the goal of the Hawaii team was to provide an appendix to the state emergency plan regarding maternal and infant health, but was revised to develop an evidence-based, comprehensive strategic plan that integrates communities and stakeholders that is supported by senior leaders.

There were several strengths of the ALC on Emergency Preparedness and Response for Maternal & Child Health (EP&R MCH), including:

• AMCHP provided training sessions, technical assistance and an opportunity for several of the team members to network with ALC peers
• Guidance and leadership was provided which facilitated discussion on specific and overlooked areas of need.
• The completion of training sessions, reports and a checklist that highlighted the gaps in planning nationwide.
• The multidisciplinary nature of the Hawaii team created broader insight.

Two of the most beneficial outcomes of the ALC were:

• brought awareness to the topic of EP&R MCH for those in the ALC, who in turn spread awareness to other colleagues and partners, and
• it allowed for the creation of new professional relationships that are/will be critical in a response. The latter was of benefit during the COVID-19 pandemic when information and resource dissemination were needed.

There were also several areas of improvement identified during the ALC:

• The lack of understanding from both internal and external partners in Hawaii (outside of the team) of the specific needs of pregnant and post-partum women, infants and children during an emergency or disaster. This made it difficult for the team to garner support to meet its primary objective, as well as complete secondary tasks in a timely fashion.
• There is a lack of data in this area, from which to assess needs specific to Hawaii. There are EP&R questions in the Hawaii PRAMS survey, but more data collection is needed.
• Greater support to build awareness at a senior level within the Department and across Departments is needed. This would underscore the need to revise emergency plans to include this population, which requires support from the partners involved in writing and implementing plans.
• There is a need for continued technical assistance in general, and for guidance in developing strategies in particular.
• There is a need for additional staff to champion the efforts.

Secondary tasks and projects that came out of the initial ALC focused on outreach materials and included an informal presentation to Community Health Center (CHC) leadership, along with a survey. The survey found the CHCs would distribute such materials if it was produced and provided to them. Another survey to the local chapter of the American College of Obstetricians and Gynecologists (ACOG) was planned but was stalled due to pandemic response efforts.

Although, the AMCHP ALC concluded several years ago, the Hawaii team continued to meet monthly until the pandemic, after which meetings have become sporadic. Membership has evolved and includes members from the State Breastfeeding Workgroup (Nest for Families).

The Hawaii ALC group helped disseminate a COVID-19 handout for pregnant and breastfeeding women and helped translate it into several languages for statewide use. The need for this emerged from Medical Reserve Corps (MRC) volunteers who were providing food and baby supplies to families in home isolation and quarantine. The needs of families with infants was distinct from other families and individuals: baby food, distilled water, diapers and cleaning supplies. Pregnant women also had special needs. MRC volunteers were questioned about disease transmission, specific to their situation. The information was used by MRC volunteers for these families when supplies were provided.

COVID-19 Lessons (to date) The COVID-19 pandemic identified gaps in planning and operations for many vulnerable and disparate populations, many of which will continue to be addressed. Pregnant women were a population that required special consideration for disease implications. Mental health for pregnant, post-partum and lactating women may also have been impacted, as hospitals and birthing centers restricted visitors and social distancing created a feeling of emotional isolation for many.

Birth plans needed to be altered and medical visits may have brought increased concern for disease exposure. In addition, not all families had post-birth support from extended family due to social distancing, quarantine and isolation. Due to the novelty of the disease, there was a dearth of data on the effects of COVID-19 for pregnant and lactating women. There was also a need to have information translated into multiple languages. All of these issues left families concerned or unsure of how the disease would impact them and their baby.

Title V Preparedness Efforts Hawaii’s Title V Director participated in the development of the State COVID vaccination plan and served as the liaison for the early childhood/childcare providers to ensure priority vaccination status was given to this sector. He also provided regular communication updates during the pandemic to members of the early childhood community through the State Early Learning Board, which is a public-private governing board tasked with formulating statewide policy relating to early learning. FHSD programs and services helped share information with their constituents and providers and families as applicable.

During the pandemic, Title V programs provided leadership for their programs to develop policies and procedures in alignment with CDC and DOH guidance, federal and state mandates, and the governor’s emergency proclamation orders. Adaptations to programs had to be considered for the health and safety of staff, families, and communities.

• Newborn metabolic screening worked with hospitals and families to ensure timely specimen collection for newborns. COVID had some impact on families and physicians because some doctors’ offices were closed, and some families were afraid to visit hospitals and clinics. However, the program ensured most newborn screens were completed and identified missed babies for follow-up for screening. Infants at risk were transferred to a hospital or referred to Hawaii Community Genetics for follow-up care. The program maintained a screening rate of 99.8%.
• Newborn hearing screening continued to ensure babies had a hearing screening before one month of age and worked with the hospitals, hearing screening programs, and midwives. Hawaii saw higher rates of home births, possibly due to concerns over exposure to COVID-19 at hospitals. The program adapted to work closely with midwives to ensure hearing screenings were completed. 
• Home visiting followed guidance from HRSA to suspend in-person home visits during the governor’s mandatory closures. Home Visiting staff continued to support providers modify services and continue participant recruitment during the pandemic. Support was offered to providers to ensure equitable access to remote services for enrolled families. Home Visiting service programs continued to engage families using videoconferencing or through telephone calls to maintain contact with families while maintaining fidelity to the evidence based service models.
• WIC waivers were extended by the USDA, allowing Hawaii WIC clinics to provide all services remotely by phone, mail, and electronic correspondence. Hawaii WIC temporarily added new shelf-stable foods during times when certain items were hard to find or were unavailable in stores. Hawaii completed rollout of eWIC, the electronic benefits transfer (EBT) system, that replaced use of paper checks. The WICShopper app was made available for download that allows participants to review available food benefits, scan products to identify WIC-allowed foods, find WIC clinics, WIC-approved stores, and view recipes on a smartphone.
• Early Intervention Section (Hawaii’s IDEA Part C Agency) services were modified to phone visits and/or videoconferencing. Zoom is used since it provides secure service versus FaceTime which does not meet confidentiality requirements.
• Children and Youth with Special Health Needs Program staff continued to communicate with youth and families through telephone, email, and videoconferencing and continue to check in with families to ensure their health concerns are being addressed.

PRAMS Emergency Preparedness Data In 2016, Hawaii was one of the first states to include an eight-part, pre-tested, standardized disaster preparedness question that measured family preparedness behaviors on their PRAMS questionnaire. The eight preparedness behaviors can be generalized into three categories: having plans, having copies of important documents, and having emergency supplies. A CDC Division of Reproductive Health intern analyzed the data for an Emergency Preparedness Summit and completed an unpublished manuscript. The results found Hawaii’s mothers were relatively well-aware and prepared for emergencies with 79.3% reporting at least one preparedness behavior. The high rate was attributed to Hawaii’s experience enduring severe hurricanes and the annual state hurricane season educational campaigns.