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Public Health 101 An Introduction for Stakeholders A Trainer’s Guide. Tarrant County Public Health Public Health Preparedness Division & Southwest Center for Advanced Public Health Practice 2009. Course Outline. Introduction to Public Health Public Health Preparedness

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public health 101 an introduction for stakeholders a trainer s guide

Public Health 101An Introduction for StakeholdersA Trainer’s Guide

Tarrant County Public Health

Public Health Preparedness Division


Southwest Center for

Advanced Public Health Practice


course outline
Course Outline
  • Introduction to Public Health
  • Public Health Preparedness
  • Incident Command System (ICS)
  • Public Health Response to Emergencies
  • Strategic National Stockpile (SNS)
  • Introduction to Epidemiology
  • Isolation and Quarantine
  • Case Study 1: Hepatitis A outbreak
  • Case Study 2: Avian Influenza outbreak
  • Case Study 3: White Powder Incident
course objectives
Course Objectives
  • Identify the basic roles and responsibilities of a local public health agency
  • Discuss the importance of collaboration between public health and first responders in the event of an emergency
  • Provide examples of events that are within the scope of public health preparedness
  • Explain and demonstrate how public health utilizes ICS during emergencies
  • Describe functions of public health surveillance and alerting system for law enforcement/first responders
  • Describe several of the main steps in an outbreak investigation
  • List scenarios where public health and first responders are most likely to interface
what is health
What is Health?
  • Health is a state of complete physical, mental and social well- being and not merely the absence of disease or infirmity.
tarrant county public health s vision mission
Tarrant County Public Health’s Vision & Mission

Vision: The Tarrant County Public Health Department assures, protects and promotes the overall health and well-being of our residents

Mission: Safeguarding Our Community’s Health

public health objectives
Public Health Objectives
  • Prevent epidemics and the spread of disease
  • Protect against environmental hazards
  • Prevent injuries
  • Promote and encourage healthy behaviors
  • Respond to disasters and assist communities in recovery
  • Assure the quality and accessibility of health services

The American Public Health Association

tarrant county public health services
Tarrant CountyPublic Health Services
  • Personal Health Services (clinical services)
    • Immunizations
    • STD/HIV testing and counseling
    • Chronic disease counseling
    • Tuberculosis services
    • Family planning and maternal & child health services
    • Travel health services

Providing direct clinical services is only one part of the mission of a local health department

population based public health services
Population BasedPublic Health Services
  • Environmental Health
  • Infectious Disease Control and Investigation
  • Laboratory Services
  • Health Education Services
the public health system
The Public Health System

Federal Agencies

State Agencies

Local Agencies


Public Health’s Many Partners





Community Centers



Health Department



Elected Officials


Mass Transit


Nursing Homes


Environmental Health

Civic Groups



Tribal Health

Laboratory Facilities

Drug Treatment

Economic Development

Mental Health


which level of government is responsible for protecting public health
Which level of government is responsible for protecting public health?
  • 10th Amendment to the U.S. Constitution:
    • All powers not delegated to the Federal government shall be reserved for the state governments
  • States are responsible for protecting public health
what is public health preparedness
What is Public Health Preparedness?





and equipment

necessary to

maximize the

ability to prevent,

respond and

recover from

major events.”


public health preparedness builds infrastructure for
Public Health PreparednessBuilds Infrastructure for:

Everyday health threats

Infectious & foodborne diseases

Public Health Emergencies

Bioterrorism, pandemics

preparedness and bioterrorism
Preparedness and Bioterrorism

What is bioterrorism???

-- The use of...

  • Bacteria
  • Viruses
  • Parasites
  • Their by-products

…in a terrorist act.

preparedness and bioterrorism1
Preparedness and Bioterrorism
  • Possible agents of bioterrorism
    • Anthrax
    • Smallpox
    • Plague
    • Botulism
preparedness and bioterrorism2
Preparedness and Bioterrorism
  • What might an attack of bioterrorism look like?
    • Not necessarily explosions or plumes of smoke
    • May not be readily apparent and detectable
    • Sick people arrive at hospitals or doctors’ offices
    • Delayed recognition and diagnosis
    • Population panic
why is public health a responder
Why is Public Health a Responder?
  • Public health has been involved with preparedness issues long before 9/11/2001
  • Public health preparedness involves more than just bioterrorism
roles in preparedness
Roles in Preparedness


  • Outbreaks from contaminated food or water, infectious diseases, etc.
  • Natural disasters: hurricanes, floods, fires
roles in preparedness1
Roles in Preparedness
  • Planning
  • Coordination/Collaboration
  • Training and Exercise
  • Response
  • Evaluation and Corrective Action

Collaboration is critical to success!

roles in preparedness2
Roles in Preparedness
  • Examples of public health roles:
    • Health threats investigator
    • Public service/media
    • Post-event tracking
    • Environmental investigators
early detection of health threats
Early Detection of Health Threats


  • KEY GOAL: protecting community assets and reducing illness and death
  • HSPD-21 defines key directive for state and local biosurveillance
  • Collaboration on detection response critical to achieving key goal
  • Initial detection and response is LOCAL
public health biosurveillance systems
Public Health Biosurveillance Systems
  • Automated collection from 56 hospitals in NC Texas, 16 ISDs and pharmacies 24/7/365
  • Automated alerting
  • Local initial response
  • Special secure web-based communication system
incident command system
Incident Command System
  • Allows a more effective, efficient response to emergencies
  • Examples:
    • HazMat incidents
    • Terrorist incidents
    • Natural disasters
    • Incidents involving multiple casualties
incident command
Incident Command

LHD’s use ICS

Command & Control

PH Resources & Personnel

Communicate to partner agencies

incident command public health
Incident Command & Public Health
  • In the event of a public health emergency the public health director will interact with the local EOC or incident command post.
  • The public health Department of Operations Center (DOC) may be activated to facilitate tactical communications.
notifying public health
Notifying Public Health
  • Public health is a valuable & relevant partner
  • Public health is available 24/7
  • System in place to triage calls during business & non-business hours
notifying public health 24 hour hotline
Notifying Public Health(24 Hour Hotline)
  • If you need their help in an emergency call, 817-994-3708
  • Public health can’t respond if you don’t call them
  • Public health will always respond in a timely manner
public health responding to emergencies
Public Health Responding to Emergencies
  • In what type events would you expect Public Health to assume lead role for providing health and medical services ?
public health preparedness summary
Public Health Preparedness Summary
  • Build public health infrastructure to respond to threats from:
    • Bioterrorism
    • Natural disasters & disease outbreaks
  • Requires collaboration between agencies:
    • Planning
    • Training & exercises
    • Response
    • Communication
    • Management of resources
group exercise crypto outbreak
Group Exercise:Crypto Outbreak

Cryptosporidium (crypto) is a microscopic parasite caused by fecal contamination in water. It most often manifests in public swimming areas.

group exercise crypto outbreak1
Group Exercise:Crypto Outbreak

Lake Sharon a popular public swimming lake is source of a large crypto outbreak.

group exercise crypto outbreak2
Group Exercise:Crypto Outbreak

Based on the ICS 201…

  • Complete an ICS 202
  • Write objectives
  • Write safety message
  • Secure perimeter
  • Take into account environmental hazards
strategic national stockpile sns
Strategic National Stockpile (SNS)
  • A national stockpile available in the event of a major terrorist attack against the civilian US population
  • National repository consisting of:
    • Pharmaceuticals (i.e., antibiotics and vaccines)
    • Antidotes and antitoxins
    • Medical and surgical supplies
strategic national stockpile
Strategic National Stockpile
  • SNS is a federal asset deployed locally after a major disaster
    • The governor of the affected state requests deployment of SNS from:
strategic national stockpile1
Strategic National Stockpile
  • Delivered within 12 hours of federal decision to deploy SNS assets
    • 12-hour “Push Package”
    • Push packages are warehoused in strategically- positioned locations around the US
local response to strategic national stockpile
Local Response to Strategic National Stockpile

SNS deployment is a large-scale event requiring adequate:

  • Security

Pre–determined Points of Distribution

  • Crowd control
  • Traffic control
local response to strategic national stockpile1
Local Response to Strategic National Stockpile
  • Essential that First Responders and others in contact with exposed civilians are the first to be medicated
local response to strategic national stockpile2
Local Response to Strategic National Stockpile
  • Must prepare to dispense medicine to a huge number of people in a relatively short time span
local response to strategic national stockpile3
Local Response to Strategic National Stockpile
  • Expect to work with Public Health:
    • Work collaboratively
    • Implement emergency response according to prior planning
    • Have conducted prior training and exercises
    • Interagency Cross-Training
local response to strategic national stockpile4
Local Response to Strategic National Stockpile
  • Remember the 5 P’s . . .

Prior Planning Prevents

Poor Performance

what is epidemiology
What is Epidemiology?

Study of the spread and causes of diseases or events in specified populations, and the control of health problems.

epidemiology concerned with outbreaks
Epidemiology concerned with OUTBREAKS
  • An adverse health event involving an unusual increase in cases among a certain population of individuals, within a certain period of time, in a certain location
areas of epidemiology
Infectious diseases





Areas of Epidemiology
epidemiology study examples risk or exposure outcome
Epidemiology Study Examples(risk or exposure outcome)
  • Smoking (exposure) increases the risk of developing Lung Cancer (outcome)
epidemiology study examples risk or exposure outcome1
Epidemiology Study Examples(risk or exposure outcome)
  • Eating undercooked hamburger (exposure) increases the risk of infection with the bacteria E. coli (outcome).
epidemiology study examples risk or exposure outcome2
Epidemiology Study Examples(risk or exposure outcome)
  • Getting a flu shot (exposure) decreases the risk of becoming ill with the flu (outcome).
simplified steps in an outbreak investigation
Simplified Steps in an Outbreak Investigation
  • Confirm outbreak and verify diagnosis
  • Perform field work and complete study
  • Implement control and prevention measures
  • Communicate findings
disease reporting notifiable diseases
Disease Reporting: Notifiable Diseases
  • Texas healthcare providers are required by law to report patients with certain diseases and conditions:
    • Report immediately
      • Potential BT agents (anthrax, smallpox, plague)
      • Botulism (foodborne)
      • Viral hemorrhagic fever, including Ebola
      • Other selected contagious serious diseases that may affect children and immune compromised or un-protected victims
case study 1 hepatitis a outbreak
Case Study #1: Hepatitis A outbreak

Scenario: Hepatitis A outbreak in Texas in 1997

hepatitis a symptoms
Hepatitis A symptoms
  • Jaundice (yellowing skin)
  • Fatigue
  • Abdominal pain
  • Loss of appetite
  • Nausea
  • Diarrhea
  • Fever
hepatitis a background information
Hepatitis A Background Information
  • Hepatitis A virus is found in the stool (feces) of persons infected w/ hepatitis A 
  • Virus found in food or water contaminated by the infected individual
hepatitis a transmission
Hepatitis A Transmission
  • Direct person-to-person spread:
    • Putting something in the mouth that has been contaminated by the stool of a person with hepatitis A (households, day care centers)
    • Contaminated blood or blood products
  • Ingestion of contaminated food or water
    • Infected food handlers during preparation
    • Prior to food preparation:

When item is grown, harvested, processed, or distributed

hepatitis a transmission1
Hepatitis A Transmission
  • Transmission of hepatitis A during food preparation:
    • Ex: infected food-handler fails to wash hands thoroughly between using the restroom and preparing food
hepatitis a transmission2
Hepatitis A Transmission
  • Transmission of Hepatitis A prior to food preparation:
    • Ex: Contamination occurs in fields where item is grown and harvested
hep a transmission summary
Hep A Transmission Summary
  • Transmission of hepatitis A:
    • Contaminated food
      • Infected foodhandler
      • Specific food item
    • Contaminated water
problem has been detected
Problem has been detected

In this scenario:

  • Hepatitis A cases have been found among students or staff in four different school districts in Texas
infectious agent has been verified
Infectious agent has been verified

The diagnosis of Hepatitis A has been verified (lab confirmed)

determined magnitude
Determined Magnitude


** Unusually high number of cases among:

  • school-aged children
  • Within school districts in the same county
  • Similar time period
  • What do you do next?
next steps
Next Steps
  • Identify those who are ill (cases) and determine what exposures they have in common
  • Identify those who are NOT ill (controls) and ask about the same exposures as with the cases
exposure history interviews
Exposure History Interviews
  • How do we do this?
    • Obtain contact information
    • Interview for common exposures (specific food item/ water source, ate at same restaurant, etc.)
seek additional cases of illness
Seek additional cases of illness
  • Notify private MDs, Emergency Departments, Labs, etc. to look for and report additional cases of Hep A to the health department
gather analyze data
Gather & Analyze Data
  • Investigators gather and analyze data and information from the interviews
hypothesis about causation
Hypothesis about causation
  • Investigators determined:
    • Transmission via contaminated water was not viable
    • Transmission by an infected food handler was not plausible
hypothesized causal agent
Hypothesized causal agent
  • Interviews did implicate a contaminated food item:
    • Frozen strawberries from Mexico
implement prevention control measures
Implement Prevention & Control Measures
  • Based on the hypothesis, implement prevention/control measures
  • GOAL:

Prevent additional cases of illness

prevention control measures
Prevention & Control Measures
  • Administer shots of immune globulin (IG)
  • Treatment is effective if given within 2 weeks from the time the strawberries were consumed
prevention control measures1
Prevention & Control Measures
  • Traceback contaminated frozen strawberries to the original source
  • Recall any lots still in distribution
prevention control measures2
Prevention & Control Measures
  • US Department of Agriculture (USDA) recommends placing an immediate hold on all unused product from the distributor
hepatitis a outbreak summary
Hepatitis A Outbreak Summary


Outbreak investigation involves:

  • Detecting a problem
  • Confirming the diagnosis
  • Identifying infected individuals
  • Determining how people are getting ill
  • Implementing control measures to prevent further spread of illness
isolation and quarantine protocol
Isolation and Quarantine Protocol

Tarrant County Public Health

history of quarantine
History of Quarantine
  • In the fourteenth century, to protect cities from plague epidemics, ships arriving in Venice from infected ports had to sit at anchor for forty days before landing.
  • “Quarantine” is derived from the Latin word quaresma, meaning forty.
  • The separation of someone who’s infected or contaminated from others so that the infection or contamination is not spread
  • Limitation of freedom of movement of a well person who’s been exposed to an infectious agent
what does it mean to be isolated or quarantined
What Does it Mean to be Isolated or Quarantined?
  • No contact with any new people
  • Can not leave home or place of containment
  • For evaluation and verification purposes patient needs to check in with Public Health every day
what is voluntary compliance
What is Voluntary Compliance?
  • Voluntary compliance with isolation, quarantine or other control measures means a patient cooperates and complies with Public Health’s instructions to comply with the recommended control measures in order to prevent the spread of disease.
what is involuntary detention
What is Involuntary Detention?
  • This is what Public Health will pursue if an individual does not voluntarily comply with an ordered control measure.
what is the health and safety code
What is the Health and Safety Code?
  • This is the law of the State of Texas regarding various “control measures.”
  • This is codified as Chapter 81
to what or who can control measures be imposed
To What or Who Can “Control Measures” be Imposed?
  • Person (s)
  • Groups (5 or more individuals)
  • Area (city block, ZIP code, county)
    • Buildings (hospital, hotel, business)*
    • Common Carrier (plane, bus, train)*
who can enforce these rules
Who Can Enforce these Rules?
  • Local law enforcement must enforce an order issued by local health authority.
a pandemic is a world wide epidemic
A Pandemic is a World-Wide Epidemic
  • A new bacteria or virus that can

infect humans

  • Nearly all people have no immunity to the new organism
  • High mortality rate
  • Easily spread from person to


case study 2 influenza outbreak
Case study #2: Influenza Outbreak
  • Background on avian influenza:
    • Strains of influenza that infect birds
    • Circulate among wild water birds
    • Bird-to-bird transmission via:
      • Fecal material
      • Saliva
      • Nasal & respiratory secretions
background avian influenza
Background – Avian Influenza
  • Varying severity and infectiousness among birds
  • The highly pathological avian influenza (HPAI) is the virus that is a pandemic among migrating water fowl.
  • Potential to combine with human flu virus to produce a “new” influenza transmissible to humans that could be lethal.
viral reassortment
Viral reassortment
  • Mixing of viral genes from two different animal species simultaneously


Human infected with human and avian influenza virus at the same time

influenza virus transmission
Influenza Virus Transmission

Influenza viruses have the potential to mutate rapidly and gain the ability to spread from:

  • Birds to farm animals (i.e., pigs)
  • Animals to humans
  • Birds to humans (directly)
avian influenza virus transmission concerns
Avian Influenza Virus Transmission Concerns
  • Strain efficiently transmitted between birds and humans
  • Strain efficiently transmitted from human to human
influenza outbreak scenario
Influenza Outbreak Scenario


A highly infectious form of avian influenza begins to circulate among poultry at a farm in Hong Kong.

influenza outbreak
Influenza Outbreak
  • The owner of the farm also has several pig pens
  • The pig pens are located right next to the bird cages
  • The feed troughs for both the pigs and poultry are often interchanged
influenza outbreak1
Influenza Outbreak
  • The avian flu virus mutates and infects several of the pigs.
  • The virus mutates again and is transmitted from one of the pigs to the farm owner.

Bird →Pig →Human

influenza outbreak2
Influenza Outbreak
  • The farm owner wakes up one morning suffering from:
    • Fever
    • Sore throat
    • Coughing
    • Muscle aches
influenza outbreak3
Influenza Outbreak
  • In the afternoon, he travels into the crowded capital city to sell his poultry at the local market.
  • He is in extremely close contact with customers for several hours.
influenza outbreak4
Influenza Outbreak
  • A couple days later, several of the customers from the market begin to show symptoms of flu-like illness:
    • Coughing
    • Fever
    • Sore throat
    • Muscle aches
influenza outbreak5
Influenza Outbreak
  • Several of them work in the kitchen of a nearby hotel restaurant
  • The restaurant is popular among Americans on business trips in Hong Kong.
influenza outbreak6
Influenza Outbreak
  • A Tarrant County resident traveling in Hong Kong on a business trip stays at the hotel.
  • He eats at the hotel restaurant on an evening in which one of the infected workers is preparing food.
influenza outbreak7
Influenza Outbreak
  • The businessman is infected with flu.
  • Within a few days of eating at the restaurant, he exhibits flu-like symptoms.
  • The following day, he flies home to DFW.
influenza outbreak9
Influenza Outbreak

Within days after the Tarrant resident returns home, local hospitals see an increase in patients presenting with:

  • coughing
  • fever
  • muscle aches
influenza outbreak10
Influenza Outbreak
  • Local physicians report similar trends in symptoms seen in recent days in their private practices.
influenza outbreak11
Influenza Outbreak
  • Additionally, FWFD & Medstar report increased calls for transporting individuals with flu-like illness.
  • Tarrant County biosurveillance system showing unusual increase in flu-like symptoms in both ED and outpatient.
  • Alerts issued to LE/FR
influenza outbreak12
Influenza Outbreak
  • Over the next couple days, several EMS workers who’ve been transporting ill patients, call in sick to work complaining of flu-like symptoms.
  • The work-force loses capacity because so many employees have fallen ill.
question 1
Question 1
  • What factors might be contributing to EMS staff contracting influenza?

(Hint: prior influenza vaccination likely would NOT be effective in preventing infection from an avian flu virus)

  • Staff were not taking appropriate protective measures around infected persons:
    • Not regularly washing hands after contact with sick individuals
    • Failing to wear personal protective equipment (masks and gloves)
    • Failing to disinfect contaminated surfaces and medical equipment after transporting patients
question 2
Question 2
  • Could this influenza outbreak have been prevented completely?

Highly unlikely :

  • Population has little to no immunity against a new avian flu virus strain
  • Prior influenza vaccination not protective against avian flu virus strain
  • Minimum of 6 months needed to develop a new flu vaccine

However . . .

question 3
Question 3
  • Could the magnitude of this outbreak have been reduced?

Yes – it is likely the magnitude of the outbreak could have been reduced by:

  • Earlier attention to health alerts
  • Regular hand washing after contact with patients
  • Wearing personal protective equipment (masks, gloves, gowns)
  • Regularly disinfecting surfaces and medical equipment
question 4
Question 4
  • Would a quarantine be required?
  • Yes - general quarantine precautions would apply:
    • An infected patient (with SARS, Avian, TB or Panflu) on an international flight CAN be detained at the airport terminal
    • CDC, airport and local public health authorities can request flight manifests and have passengers undergo medical screening for their safety
    • A non-compliant patient can be arrested and sent to forced quarantine
question 5
Question 5
  • Why would a non-compliant person be arrested and sent to forced quarantine?
  • This is so a non-compliant patient does not endanger the public or themselves.
importance of yearly influenza vaccination
Importance of Yearly Influenza Vaccination
  • Reduce chances of dual infection with avian and human flu viruses
  • Dual infection could result in a highly virulent and transmissible strain
influenza outbreak summary
Influenza Outbreak Summary
  • It is especially important . . .
    • Wash hands or use sanitizers regularly
    • Practice good respiratory hygiene and cough etiquette
    • Don’t come to work when you are sick
    • Get a flu shot each year
influenza outbreak disclaimer
Influenza Outbreak Disclaimer


  • Currently no sustainable human-to-human transmission of bird flu have been reported
  • However, cases of human-to-human transmission continue to occur and the virus continues to mutate

Therefore, we must be prepared for this possibility

case study 3 white powder incident
Case Study #3 - White Powder Incident


  • It is early Monday morning at a major law firm in downtown Fort Worth
white powder incident
White Powder Incident
  • An office secretary is opening mail delivered over the weekend
  • She sees a suspicious looking letter with an unusual return address and excessive tape on the outside
white powder incident1
White Powder Incident
  • She opens the letter and white powder falls out of the envelope
  • She leaves the envelope on her desk and notifies a co-worker, who calls 911
white powder incident2
White Powder Incident
  • Local law enforcement and HazMat teams are notified
  • Law enforcement arrives first at the scene
  • Law enforcement implements ICS
  • Maintains chain of command and control
white powder incident3
White Powder Incident
  • Law enforcement determines that the credibility of the threat is legitimate
  • The area of the law office where the powder was found was immediately isolated
white powder incident4
White Powder Incident
  • Individuals who may have come in contact with the powder were quarantined and held for decontamination
  • The law office was evacuated
white powder incident5
White Powder Incident
  • Law enforcement requests that HazMat collect a specimen
  • HazMat team collects a sample of the white powder from the law office
white powder incident6
White Powder Incident
  • HazMat turns over the powder specimen to law enforcement to transport to the Texas Department of State Health Services for testing
white powder incident7
White Powder Incident
  • HazMat also handles decontamination of the woman who opened the letter and had direct exposure to the white powder
  • Should public health be notified about this white powder incident?
  • Who should call public health?
  • Why should public health be notified?
white powder incident8
White Powder Incident
  • YES, law enforcement should notify public health immediately
  • Public health will:
    • Send nurses and epidemiologists to interview those potentially exposed to the white powder (including first responders)
    • Determine the exposure risk and appropriate preventive and treatment measures
    • Follow up with the lab results at the Texas Department of State Health Services.
white powder incident9
White Powder Incident
  • Once all crime scene investigation and public health investigation is complete . . .
  • Public health collaborates w/ law enforcement and Fire/HazMat to determine when the building can be re-entered.
white powder incident10
White Powder Incident
  • Public health officials will start planning for post-exposure prophylaxis before test results come back
  • Test results will be confirmed within 24 hours
  • What happens next if lab results come back positive?
white powder incident11
White Powder Incident
  • If lab results are positive for a biological agent:
    • Local public health officials notified immediately
    • Law enforcement notified
    • Begin post-exposure prophylaxis of those potentially exposed
    • SNS may be requested if medical resources are insufficient
  • What happens next if lab results come back negative?
white powder incident12
White Powder Incident
  • If lab results are negativefor biological agent:
    • Law enforcement will be notified
    • Local public health notified to inform those exposed of the test results
white powder incident13
White Powder Incident

Scenario Resolution

  • Test results came back negative for anthrax and other biological agents
  • Tests determined the white powder was derived from an aspirin product
white powder incident14
White Powder Incident

Take Home Messages

  • Every white powder incident is different
  • Involves collaboration among:
    • Law enforcement
    • Fire & EMS, HazMat
    • Local public health officials
  • Efficient management requires:
    • Mutual understanding of roles and responsibilities
    • Collaborative efforts
    • Good intra-agency and inter-agency communication