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Planning for PANDEMIC FLU

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Title: Planning for PANDEMIC FLU


1
Planning for PANDEMIC FLU
Principles of Isolation and Quarantine in the
21st Century Catherine Slemp, MD, MPH WV Bureau
for Public Health November 2006
2
Objectives / Overview
  • Review Targeted and Layered Approach Concept
  • Review Disease Spread Principles and Goals in
    Addressing a Pandemic
  • Brief History of Isolation and Quarantine (I Q)
  • 21st Century Principles of I Q
  • I Q Authorities in WV
  • Activities Underway
  • Ethical considerations and principles

3
Pandemics vary in severity and Combined
approaches seem most effective (from history and
modeling) ….therefore
4
A Targeted and Layered Approach
5
Epidemiology Drives Approach (Targeted)
SAMPLE
6
A Layered Approach
Individual / Household / Agency Hand
hygiene Cough etiquette Infection control Living
space control Isolation of ill Designated care
provider Facemasks where indicated
Community Isolation of ill Treatment of
ill Quarantine of exposed Prophylaxis of
exposed School closure Protective
sequestration of children Social
distancing - Community - Workplace Liberal
leave policies
International Containment-at-source Support
efforts to reduce transmission Travel
advisories Layered screening of travelers Health
advisories Limited points of entry
7
Recent Analyses Suggest That Community Actions
May Significantly Reduce Illness and Death Before
Vaccine is Available
  • When necessary, early and uniform implementation
    of such measures as
  • School closure
  • Keeping kids and teens at home
  • Social distancing at work and in the community
  • Encouraging voluntary home isolation by ill
    individuals and voluntary home quarantine by
    their household contacts
  • Treating the ill and providing targeted antiviral
    prophylaxis to household contacts
  • Implementing measures early and in a coordinated
    way

8
Things to consider in choosing strategies
  • Disease severity
  • Information on the disease (e.g., are there high
    risk subgroups? How effective are antivirals?
    etc.)
  • Ability to practically implement the control
    measure
  • Public acceptability of the control measure
  • Secondary impacts of the measureare we doing
    more harm than good?
  • What should be implemented by communities and
    what centrally? Is a common approach important?
  • Ethical considerations

9
Understanding Disease Spread

10
Ro 2
R0 1
11
Suppression
Effect of Increasing Social Distance on
Epidemic Dynamics
Exponentiation
Ro 0.67, Progression 12432
Ro 2.0, Progression 124816
12
Ways to Increase Social Distance
  • Implement Community Shielding recommendations
  • Close or alter high risk transmission
    environments e.g. schools, daycare centers if
    supported by epidemiology
  • Cancel large public gatherings (concerts,
    theaters)
  • Minimize other exposures (markets, churches,
    public transit)
  • Encourage ill and exposed persons to stay home
    (isolation and quarantine)
  • Encourage telecommuting other worksite
    adaptations
  • Scaling back or altered transportation services
    (holiday schedule)
  • Etc.
  • Other Interventions Supporting / Adding to
    Social Distance Measures
  • COOP to minimize economic impact, enable worksite
    adaptations, sustain secondary effects of social
    distancing measures
  • Infection Control masks, hand hygiene, cough
    etiquette, barrier precautions, etc. where
    applicable.

13
(No Transcript)
14
Potential Tools in Our Toolbox
  • Vaccine Our best countermeasure will probably
    be unavailable during the first wave of a
    pandemic
  • Antivirals
  • Treatment If effective against specific virus
    that emerges, treatment may reduce disease
    duration / symptoms will have only modest
    effects on transmission.
  • Prophylaxis If virus susceptible and supply
    sufficient, may have more substantial effects on
    reducing transmission
  • Infection Control and Social Distancing likely
    should reduce transmission Strategies to
    implement many of these require clarification and
    significant advance planning.

15
Isolation and Quarantine as one of many means to
increase Social Distance
  • Isolation and Quarantine in 21st Century
  • Public Health
  • (a different tool than in prior centuries)

16
Definitions
  • Isolation
  • Separation of ill persons with contagious
    diseases
  • Often in a hospital setting, not always
  • Applied to individual(s), cohorts, populations
  • Quarantine
  • Restriction of persons who are not ill but
    presumed exposed
  • Usually in the home or a designated facility
  • Applied to individual(s), groups, or
  • communities

voluntary vs. compulsory, request vs. legal order
17
1800s Quarantine Torture, exile, and death
Death in a sailors uniform holding the yellow
quarantine flag knocking on the door of NYC
during the 1898 yellow fever epidemic
Frank Leslies Illustrated Newspaper, Sept. 1878
18
21st Century Quarantine
Collective actions for the common good
Public good
Individual liberties
Preventing Disease Spread While Safeguarding The
Health of People Infected Exposed to Highly
Dangerous Infectious Diseases Paramount to meet
needs of individuals infected and exposed
avoid stigmatizing the victims
19
10 Principles of Modern Quarantine
  • Used when exposed to highly dangerous and
    contagious disease and when resources available
    to implement and maintain
  • Encompasses a wide range of strategies, often
    used in combination with other interventions
  • Ensures rapid isolation of contagious persons
    from exposed
  • Ensures those in Q/I access to essential goods
    services, be among those prioritized to receive
    interventions
  • Lasts only as long as necessary, not more than
    incubation period

20
10 Principles of Modern Quarantine, cont.
  • Does not have to be absolute to be effective,
    therefore favors voluntary over compulsory
  • Must actively combat stigma and adhere to
    accepted ethical principles
  • Requires clear understanding of jurisdictional
    roles and legal authorities
  • Requires careful coordination and advance
    planning with many partners/stakeholders
  • Requires education, trust and participation of
    general public as well as strong leadership

21
Q-Ethical Construct
  • 1. Justifiable Harms (necessity)
  • 2. Least restrictive means
  • 3. Reciprocity (support)
  • 4. Due Process (notification appeal)
  • 5. Fairness

Construct derived from Ross Upshur, Can J PH
2002 (93)101-103
22
DUE PROCESS IN QUARANTINE AND ISOLATION
  • Flexible concept (procedures may vary)
  • Courts employ a balancing test
  • Degree of deprivation risk of erroneous
    determination value of added procedural
    safeguards
  • Common elements of due process
  • Adequate notice (written order)
  • Opportunity to be heard in meaningful time
    manner
  • Neutral decision-maker
  • Access to legal counsel

23
Misconceptions
  • Effectiveness of containment measures requires
    100 compliance
  • Isolation or Quarantine always means using a
    legal order to restrict someones activity
  • Isolation or Quarantine must be mandatory
  • to be effective

24
Misconceptions
  • Quarantine only means large geographic cordon
    sanitaire
  • The public will never accept the use of
    quarantine as a mitigation strategy

25
I Q is only one way to Increase Social
Distance
  • Community Shielding measures
  • Close or alter high risk transmission
    environments e.g. schools, daycare centers if
    supported by epidemiology
  • Cancel large public gatherings (concerts,
    theaters)
  • Minimize other exposures (markets, churches,
    public transit)
  • Encourage ill persons to stay home (isolation)
  • Encourage exposed persons to stay home
    (quarantine)
  • Encourage telecommuting other worksite
    adaptations
  • Scaling back or altered transportation services
    (holiday schedule)
  • Other interventions supporting / adding to
    social distance measures
  • COOP to minimize economic impact, enable worksite
    adaptations, sustain secondary effects of social
    distancing measures
  • Infection Control masks, hand hygiene, cough
    etiquette, barrier precautions, etc. where
    applicable.

26
Advantages of Community Shielding Approaches
  • Intuitive
  • Leverages the publics instinct for
    self-preservation
  • Cordon sanitaire conflicts with this instinct
  • Less restrictive approach than geographic
    quarantine

27
Quarantine in Pan Flu
  • Cordon Sanitairelikely limited to no
    significant applicability or usefulness.
  • Short incubation period, early period of
    communicability, and global nature of todays
    world.
  • If considered at all
  • Very early stages (first few cases / potential
    cases worldwide)
  • An attempt to prevent pandemic from occurring or
    significantly slow initial spread (buying
    time).
  • Other methods of quarantine may be usefule.g.
    voluntary, home based quarantine
  • More practical and effective
  • Builds on interest and instinct to do whats
    right / protect self and others
  • Undertaken as one of many community shielding
    measures

28
Lessons Learned from SARS
  • Different disease, but learned in Toronto that…
  • People followed public health recommendations if
  • Clearly Communicated What to do and Why
  • Supported in Accomplishing / made it as Practical
    as Possible (access to basic necessities, job
    security, financial stability for period, etc.).
    Doing this takes more than govt alone.
  • Rarely needed to use legal authority
  • Was voluntary as long as you complied
  • Had legal authority to enforce if determined
    necessary.
  • 30,000 quarantined in Toronto. Very few legal
    orders issued (lt20). Most all challenges
    dropped once learned more.

29
Legal Authorities of PH in WV
  • State 16-3-1. State director of health
    authority to quarantine and to enforce
    regulations state board of health authority to
    issue regulations to control infectious or
    contagious diseases.
  • Local 16-3-2. Powers of county and municipal
    boards of health to establish quarantine penalty
    for violation.

30
Public Health Orders
  • Authorities to issue PH Orders
  • Local Boards of Health
  • State Health Commissioner
  • Dont require declaration of emergency
  • In cases of isolation and quarantine,
  • Can be declared by BPH Commissioner or local
    Board of Health.
  • With latter, must be reported to and determined
    necessary by Commissioner as soon as practical to
    do so. Commissioner may lift if not deemed
    necessary.

31
Current Key Activities
  • Isolation and Quarantine Protocol Development
    (IDEP-DSDC-BPH) (when applicable for what
    disease, etc.)
  • Legal Workgroup Administrative Processes and
    Tools

32
Remember We have a Tool Kit of Control Measures
to Use
  • Community Shielding (many methods)
  • Hygiene measures
  • Antivirals (treatment prevention, if supplies
    sufficient)
  • Vaccine
  • Continuity of Operations Planning

33
Ethical Principles to Consider
Alexander Capron, Ethical and Legal
Considerations in Mitigating Pandemic Disease,
IOM Forum on Emerging Infections, Washington,
D.C., September 19-20, 2006
34
Ethical Principles to Consider
Alexander Capron, Ethical and Legal
Considerations in Mitigating Pandemic Disease,
IOM Forum on Emerging Infections, Washington,
D.C., September 19-20, 2006
35
Specific Ethical Considerations in Pandemic Flu
Planning
Alexander Capron, Ethical and Legal
Considerations in Mitigating Pandemic Disease,
IOM Forum on Emerging Infections, Washington,
D.C., September 19-20, 2006
36
Specific Ethical Considerations in Pandemic Flu
Planning
Alexander Capron, Ethical and Legal
Considerations in Mitigating Pandemic Disease,
IOM Forum on Emerging Infections, Washington,
D.C., September 19-20, 2006
37
Resources / References
  • Stand on Guard for Thee Ethical Considerations
    in Preparedness Planning for Pandemic Influenza.
    November 2005. University of Toronto Joint
    Center for Bioethics, Influenza Working Group
    Report. Website reference http//www.utoronto.ca/
    jcb/home/documents/pandemic.pdf
  • Alexander Capron, Ethical and Legal
    Considerations in Mitigating Pandemic Disease,
    IOM Forum on Emerging Infections, Washington,
    D.C., September 19-20, 2006. Website reference
    http//www.iom.edu/CMS/3783/3924/35857/37298.aspx

38
Seasonal Influenza
Pandemic Influenza
All Hazard Preparedness
39
Get Informed, Be Prepared!
  • RESOURCES
  • WVBPH Div Threat Prep or DSDC
  • Your Emergency Management Agency and Local Health
    Department
  • http//www.wvflu.org
  • http//www.pandemicflu.gov
  • ASTHO (www.astho.org) and NACCHO (www.naccho.org)
    Websites
  • CDC website (www.cdc.gov)
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