Preparing for and Responding to Bioterrorism: Information for the Public Health Workforce

1
Preparing for and Responding to Bioterrorism
Information for the Public Health Workforce
2
Acknowledgements
This presentation, and the accompanying
instructors manual, were prepared by Jennifer
Brennan Braden, MD, MPH, at the Northwest Center
for Public Health Practice in Seattle, WA, for
the purpose of educating public health employees
in the general aspects of bioterrorism
preparedness and response. Instructors are
encouraged to freely use all or portions of the
material for its intended purpose. The
following people and organizations provided
information and/or support in the development of
this curriculum. A complete list of resources
can be found in the accompanying instructors
guide.
Patrick OCarroll, MD, MPH Project Coordinator
Centers for Disease Control and Prevention
Judith Yarrow Design and Editing Health Policy
and Analysis University of WA Washington State
Department of Health
Jeff Duchin, MD Jane Koehler, DVM,
MPH Communicable Disease Control, Epidemiology
and Immunization Section Public Health - Seattle
and King County Ed Walker, MD University of
WA Department of Psychiatry
3
Consequence Management For Public Health Leaders
Module A
4
Consequence ManagementLearning Objectives

• Describe the role of public health in consequence
  management following a public health emergency
  and identify laws supporting this role
• Describe the legal basis for quarantine and
  potential adverse consequences and identify
  factors to consider when implementing and
  enforcing quarantine

5
Consequence ManagementLearning Objectives

• Describe the basic structure and components of
  the National Pharmaceutical Stockpile,
• How and when it is employed
• The responsibilities of state and local health
  officials in accepting and distributing the
  resources provided
• Identify the potential psychological responses,
  on individual and community levels, following a
  BT event, threat, or other public health
  emergency

6
Consequence Management Legal Basis for Local
Efforts

• State police powers give states the authority to
  prescribe within the limits of state and federal
  constitutions, reasonable laws necessary to
  preserve the public order, health, safety,
  welfare, and morals.
• RCW 70.05.070 gives the local health officer
  power to take such measures as he or she deems
  necessary in order to promote the public health.

7
Presidential Decision Directive 39U.S. Policy on
Counterterrorism

• Consequence management - response to the
  disaster, focusing on the alleviation of damage,
  loss, hardship, or suffering
• Public health, medical, and emergency personnel
• Response and Recovery phases
• State have primary responsibility for response
• Federal agencies provide assistance as needed
• FEMA has lead role

PDD-39
8
Consequence Management Federal Support

• Federal Response Plan, Emergency Support Function
  8
• Provides federal assistance to supplement state
  and local resources in response to public health
  and medical needs following a major disaster or
  emergency, or during a developing potential
  medical situation
• Directed by DHHS
• CDC lead for protecting health and safety

9
Consequence Management Other Emergency Support
Functions
ESF Function Lead Agency
5 Information and planning FEMA
6 Mass care American Red Cross
10 Hazardous materials EPA
11 Food USDA
10
Consequence ManagementNecessary Protocols and
Procedures

• Communication and informational updates
• Between staff/agency divisions
• With other coordinating agencies
• With the media and public
• Evaluation and referral of phone calls and
  requests for information or services
• Mass antibiotic prophylaxis and immunization
• Quarantine and isolation

11
Consequence ManagementNecessary Protocols and
Procedures

• Closure of public places/institutions
• Evaluating and referring reports of suspicious
  packages or substances
• Surge capacity
• Use of private resources
• Use of volunteers and outside aid
• Requesting state/federal assistance

12
Quarantine

• Comes from Italian quarante refers to the 40
  day sequestration imposed on arriving merchant
  ships during plague outbreaks of the 13th century
  
• Today broader definition
• Restriction of movement of persons, animals, and
  things that might otherwise spread a contagious
  disease
• Usually refers to population-wide measures
• Time period not specified

13
CDC Definition Quarantine vs. Isolation

• Isolation
• The separation of a person or group of persons
  from other people to prevent the spread of
  infection
• Quarantine
• Restriction of activities or limitation of
  freedom of movement of those presumed exposed to
  a communicable disease in such a manner as to
  prevent effective contact with those not so
  exposed

14
CDC Definition Quarantine vs. Isolation

• Quarantine measures may include
• Suspension of public gatherings
• Closure of public places
• Restriction of travel
• Cordon sanitaire

15
QuarantineLegal authority Local Level

• When confined to a specific locale (community,
  state) rests with local and/or state health
  authorities (police power)
• Few states have specific policies/procedures for
  deciding whether quarantine is warranted in a
  specific situation
• Be familiar with the laws pertaining to
  quarantine or that might be interpreted as
  applying to quarantine, existing in your state

16
Quarantine Legal Authority - Federal

• Section 311 of Public Health Service Act
• Allows for federal assistance to state and local
  authorities in enforcing quarantine and other
  health regulations

17
Quarantine Legal Authority Federal

• 42 CFR Part 70 - authorizes the apprehension,
  detention or conditional release of people to
  prevent the spread of specified communicable
  diseases, and federal action if state efforts
  insufficient
• 42 CFR Part 71 - authorizes CDC to detain,
  isolate or place under surveillance, people
  arriving in the US who are reasonably believed to
  be infected w/ or been exposed to certain
  communicable diseases, if necessary to prevent
  the introduction, transmission, or spread of
  those diseases

18
Quarantine and IsolationFactors to Consider

• Is there a scientific basis?
• Among Category A agents, only smallpox, pneumonic
  plague, and some VHFs transmitted
  person-to-person
• Is it practical and feasible?
• Defined geographic area of risk
• Resources to enforce and maintain
• Time period required
• Do the potential benefits outweigh the risks?

19
Medical Reasons for Isolation or Quarantine

• Isolation
• Disease transmitted person-to-person
• i.e., plague pneumonia, smallpox, viral
  hemorrhagic fevers
• Degree of isolation appropriate for mode of
  transmission (e.g., respiratory vs. direct
  contact)
• Quarantine
• Disease may be transmitted by exposed persons
  prior to recognition of symptoms or diagnosis
• Smallpox infectious at rash onset, but rash may
  be overlooked in early stages

20
Quarantine Potential Adverse Consequences

• Increased risk of disease transmission in
  quarantined population
• Mistrust of government
• Civil disobedience ? violence
• Social stigmatization
• Economic effects
• Businesses in quarantined area
• Businesses relying on goods and services from
  quarantined area

21
Quarantine and Isolation Pre-Event Planning

• Identify community facilities appropriate for use
  as quarantine sites
• Identify non-infected personnel to administer
  services at quarantine/isolation site
• Health care providers
• Laundry and waste disposal personnel
• Enforcers/access control

22
Quarantine and IsolationPre-Event Planning

• Identify means of food and supply provision to
  quarantine/isolation site
• Ensure means of communication with outside
  community

23
Quarantine and IsolationPolicies and Procedures

• When to institute
• Who is allowed access to site
• Infection control policies
• Transportation of people to site
• Within site
• Criteria for entry and departure
• When to discontinue

24
IsolationCDC Smallpox Response Plan

• Facility Categories
• Type C Contagious
• Confirmed and probable cases
• Type X Uncertain diagnosis
• Vaccinated febrile contacts without rash
• Type R Asymptomatic
• Non-febrile contacts

25
Type C FacilitiesCDC Smallpox Response Plan

• Non-shared heating, air-conditioning, and
  ventilation systems
• Exhaust all air out through HEPA filter, or at
  least 100 yds from other occupied areas
• Adequate water, heating, cooling, and closed
  window ventilation
• Able to provide high-level medical care
• (incl. vent support and cardiac resuscitation)

26
Type X Facilities CDC Smallpox Response Plan

• Same isolation and
• general supply
• requirements as
• Type C facility
• Able to provide basic medical care
• (e.g., monitoring vital signs)

27
Type R Facilities CDC Smallpox Response Plan

• May be the persons home
• or
• Hotel/motel if warranted due to logistical or
  other reasons

28
National Pharmaceutical StockpilePurpose

• Provides resources to respond to both biologic
  and chemical attacks
• Requested by governor
• Managed by Centers for Disease Control and
  Prevention

More on NPS...
28
29
National Pharmaceutical StockpilePush Packages

• 12-hour Push Packages in cargo-sized containers
  weighing approximately 37 tons each
• Located around the country at strategic locations
• Held in environmentally controlled and secured
  warehouses
• Can reach a destination within 12 hours of being
  requested

More on NPS...
29
30
National Pharmaceutical StockpilePush Packages

• Contain color-coded inventory
• Pharmaceuticals - stock rotated before expiration
• IV supplies, airway supplies, ventilators
• Bandages and personal protective equipment

More on NPS...
30
31
National Pharmaceutical StockpilePush Packages

• Materials pre-packaged for immediate dispensing
• Support staff will accompany the package
• Receiving state responsible for logistics of
  repackaging and distribution

More on NPS...
31
32
National Pharmaceutical StockpileVendor-Managed
Inventory

• Agreements with pharmaceutical manufacturers to
  make large stocks available on demand
• Shipped to arrive within 24-36 hours after
  requested
• VA hospitals have an agreement with CDC to assist
  in the procurement and maintenance of NPS

More on NPS...
32
33
Pre-Event PlanningMass Prophylaxis and Treatment

• Identification of sites
• Coordination with local hospitals, clinics,
  pharmacies, and other community facilities
• Contagiousness of disease may require separate
  site for antibiotic dispensing/immunizations
  (i.e., smallpox)
• Infection control precautions
• Identification of staff and equipment, in low-
  and high-volume situations (surge capacity)
• Establishing a record-keeping system
• Developing follow-up protocols and procedures